Health (Alteration of Criteria for Eligibility) (No. 2) Bill 2013: Second Stage (Resumed)

Question again proposed: "That the Bill be now read a Second Time."

As I was saying to the Minister for Health earlier, the major attribute of this Government seems to be to try to manipulate the debate and cover up the realities of its savage betrayal of election promises and the brutal assault it is waging against ordinary citizens and public services. Nowhere is this more evident than in the health service. The promise was that the Minister for Health, Deputy Reilly, would sort out the vast crisis in the public health service that the Government inherited from Fianna Fáil. We were to get free general practitioner care and universal health cover for everyone.

The simple fact and the reality around what we are actually seeing in the health service is another €660 million worth of cuts from the public health service on top of €3 billion of cuts since 2008; a total of 10,000 staff removed from the public health service, including thousands of nurses; up to 1,700 beds removed from the public system since 2008; ambulance waiting times that are now exceeding safe limits; recurring stories of files being lost in hospitals; the downgrading of accident and emergency wards throughout the country, including in the coming weeks the downgrading of the accident and emergency ward in the hospital in Loughlinstown in my constituency; and a total of 237 people lying on trolleys in accident and emergency wards throughout the country today.

As the Minister of State knows, I busted my shoulder last week playing football. I had to go to the accident and emergency ward in St. James's Hospital because I happened to be in town. When I went there it was like a flipping war zone. When I walked up to the window there was a woman in front of me whose head was bleeding. She asked the woman at reception how long it would be before she could see a doctor and she was told it would be between 11 and 12 hours. Needless to say, her distress was considerable at that point. I walked out because I did not have 12 hours to wait. That is the reality.

Waiting lists for hospitals are so long that hospitals are refusing to give appointments to people because the waiting times are so far out. Now, the heads of four major Dublin hospitals are saying that as a result of the Government's cuts and the cuts inflicted by the last Government patient safety is being seriously compromised in our hospitals. The public health service is an absolute shambles no matter how much the Government tries to cover it up. Last week I said to the Minister of State, Deputy Brian Hayes, that it was strangely appropriate that the figure for cuts this year was €666 million, coincidentally, the mythical number of the beast from the Book of Revelations in the Bible.

Deputy Boyd Barrett would make a very good stand-in for "The Omen".

Absolutely, that is what it is beginning to look like: a horror movie. If it was not so serious, one could make a film out of it and call it "The Return of the Beast, 666", produced by the troika, directed by Deputy Michael Noonan and staring, in the lead role as the beast, the Minister for Health, Deputy James Reilly, bringing death and pestilence to a hospital near you. Of course, it is not funny and it is not a play. The reality is a horror for vast numbers of people who are trying to access our public health system.

Now, on top of all that, the Government is going to attack medical card provision for the elderly and the chronically sick. It is going to try to take medical cards away from as many people as it possibly can under the interesting term "medical card probity". The Government is going to increase prescription charges and axe the little tax relief that people who have been forced to take out private health insurance have. This will result in 90% of people who are having to pay through the nose for private health insurance, because they know the public system is a mess, no longer being able to afford that cover and they will be forced back into the public system, which cannot cope as it is. Then, they will have to pay through the nose because they will not have medical cards.

The Government says people will get a general practitioner visit card. What this means is that there will be few savings in terms of the money the Government pays out to GPs per medical card, but the people who are really sick and who must go to hospital will suffer most because they will have to pay €100 to go to the accident and emergency ward, €75 to stay overnight in hospital, €75 for investigative procedures and €144 of the costs of their medication before those costs are covered. The Government will hit precisely the sickest people and the chronically ill. They are the people who will suffer. One could not make it up.

Then, the Government tries to cover this by saying that these people have gold-plated incomes and €600. However, if a person is sick and has to go to hospital regularly for procedures or to accident and emergency wards or whatever, that money will soon evaporate in trying to cover those costs. The sicker a person is, the more it costs and the more a person needs the provision. However, the Government will rob precisely that medical card cover from people when they most need it.

The other dastardly aspect of this is the Government's claim in response to the outrage and outcry about the attack it is waging on medical card cover for the elderly and the sick. The Government says it will give out discretionary cards to anyone who really needs them. When a person is sick, old or maybe even dying, he does not have much time to wade through the bureaucracy of making an application for a medical card. That is precisely the last thing a person should have to deal with in those circumstances, especially since he must now deal with the new centre in Finglas, which cannot cope, even now, which constantly loses applications and which is in an absolute mess. At least in the old days one could go to the HSE office in the local area, talk to a real human being and explain that a person is very sick, has particular circumstances and make an appeal for a medical card. However, now when a person is sick he must contact a post office box, not a human being, and get the run-around. It is absolutely outrageous.

The alternative to this is what we have always proposed: real universal free health care for everyone and a national health service paid for through progressive taxation. Of course, the Government will not provide for this because it is unwilling to impose a little extra tax on the wealthiest in our society, the big corporations or on the accumulated wealth of the richest people. Instead, the Government is unloading the cost on the elderly, the sick, the young and the vulnerable. It is a disgrace and this Bill is a disgrace.

When one looks closely at this new legislation, namely, the Health (Alterations of Criteria for Eligibility) (No. 2) Bill 2013, one perceives clearly the type of society that is emerging from the fallout of the economic crisis. Sadly, I must state today it is not the type of new Ireland of which I wish to be part. At the last election of 2011, all Members were elected on a platform of change, reform and honest politics. This is what people on the doorsteps told all politicians and all candidates to do. I remember well the people saying that all politicians should do their best to bring about change and reform. They also told us to do the right thing because the wrong thing had been done in the past and the tone on the doorsteps was for a bit of old-fashioned public service. However, doing the right thing or good public service does not mean one should hammer the senior citizens, the sick or the disabled. The purpose of this Bill is to do this to the senior citizens and that is completely unacceptable. It also is linked to the broader economic debate to which I will refer in more detail later.

A society that does not look after its senior citizens is a society without a heart. A society that does not look after its sick and disabled is a society without compassion and this must be at the heart of this legislation today. When one digs further into the legislation, one learns the Bill reduces the income limits for medical card eligibility for the over-70s. They are reduced from €700 to €600 for a single person and from €1,400 down to €1,200 per week for couples. Those who lose their medical cards as a result of this change will become eligible for a GP-visit card but such cards cover only the costs of consultations and do not cover many of the other services available free of charge to medical card holders. This is what is proposed in this legislation. This reduction in income limits is being introduced to reduce expenditure on medical cards for the over-70s or in other words, the code is emerging here. It is forecast that this measure will generate €12 million in savings during the second half of 2013 and €24 million in a full year. That is what this legislation is about. It is not about reform but is about attacking senior citizens and the over-70s. It is about looking for €24 million and, as my colleague, Deputy Boyd Barrett, noted, when Members of the Technical Group put forward proposals in respect of funding many of these provisions, they are dismissed out of hand and not considered or taken up. This is even though a number of times recently, the troika happened to agree with my colleagues in the Technical Group on how money can be saved in respect of reform of the health service, electronic prescriptions and many other reforms that have been put on record. Consequently, I suggest the Ministers opposite should open their minds and hearts and look at alternatives, rather than screwing and hammering the over-70s.

I also note the legislation allows for data sharing between the Health Service Executive, HSE, and the Department of Social Protection and between the HSE and the Revenue Commissioners. This will include the sharing of personal data, including sensitive data, between these bodies for the purposes of assessing and reviewing entitlements and liability for taxes and charges. The Data Protection Commissioner must be consulted before the data can be shared and Members should be highly respectful about and conscious of this matter. The Data Protection Commissioner also should do his or her job in respect of this issue.

While that is the purpose of this legislation, I will now turn to considering the present and past positions in respect of this broader debate. Between 2001 and 2008, people aged 70 and over had an automatic right to a medical card based on their age. In January 2009, the automatic entitlement of the over-70s to a medical card was withdrawn, a means test was introduced with the current income limits and savings of approximately €20 million were anticipated arising from a reduction of approximately 5% in the number of people aged 70 and over who qualified for a medical card. This is the history of the measure. Another study found that 97% of those aged 80 or more had a medical card, compared with 91% of those who are aged between 70 and 79. Within broader society, 74% of the general population visited a general practitioner, GP, at least once a year. However, 94% of people aged 70 or more visited a GP at least once a year. In other words, this figure of 94% underlines the need of the over-70s for a medical card, as they need to be supported in their retirement years. These are the people who worked for this country and who for 40 or 50 years paid their taxes into the State. It is one of the issues in which one should be respectful of them. As for the frequency of visits, the same study found that the average number of GP consultations increases with age. For example, the 18 to 24-year olds average 2.4 visits per year but this figure rises to 5.4 consultations for those who are aged 70 or more. In other words, the figure almost rises to six visits per year. Consequently, Members can see there is a need to look after the senior citizens

I am delighted the Minister of State, Deputy Brian Hayes, is in the Chamber because this debate about medical cards is interlinked with, and connected to, the broader political and economic debate. One issue to which Members are not facing up, if they are to try to support the people, is that of the debt. There have been real repercussions as a direct result of all that bank debt and the Government now is going around trying to save a few million euro here and there. It first had a go at disabilities and cut special needs services, it is now after the medical cards and it is trying to strip down the health services. In addition, the Government is examining issues in respect of education, as well as driving the youth from the country through reduced social welfare payments. Moreover, it is driving more people into early graves after the austerity budgets. This is what is taking place at present and the debt issue cannot be ignored as it is linked to this debate today. Incidentally, although it did not receive much coverage, I commend members of the Ballyhea group that came to Leinster House yesterday. They launched their campaign and are doing an excellent job in highlighting the fact that we must do something about this in the context of a broader long-term strategy. Every element of the less well off in society, including the young and the retired, has been attacked as a result of the economic crisis. However, while the attack is on senior citizens in this debate, all the while the Government has pointedly stayed away from those who can most afford to pay.

Meanwhile, the Government is paying huge annual interest on the bank debt borrowings. On the €25 billion in promissory notes bonds, it is paying approximately €210 million. On the almost €20 billion we owe Europe, if one takes an average rate of 4%, it is paying nearly €800 million. On the €5.6 billion that NAMA contributed to the banks, the lost interest on that may amount to a further €200 million per annum. This is a lot of millions of euro for a broken nation to be paying to its European overlords for the privilege of having bailed out the banks and bondholders and their own common currency, and it is important to make that point. While the Government imposed new universal taxes and charges on homes, water, pensions and medical records, it is losing out on the potential interest on the €20.7 billion taken from the National Pensions Reserve Fund of up to €1 billion per year, which is 1,000 million euro. Members should consider what could be done with that money. While the interest alone is substantial, what if the State had that money back? What could be done in terms of investment or in kickstarting the Irish economy back into life without being obliged to do what is taking place in this Chamber today? This is not a debate about health or about reform; it is a debate about generating €12 million in savings, rising to €24 million in a full year. Moreover, as has been mentioned by my colleagues, these savings are part of the €781 million in savings in the health budget that budget 2013 set out to achieve and are included in the overall reduction of €323 million in the cost of primary care schemes. Unless these issues are considered and unless Members look at the facts, they are in serious trouble.

I am delighted that the Chairman of the Joint Committee on Health and Children, Deputy Buttimer, has entered the Chamber because he needs to hear this straight. He needs to hear the facts and the reality. I also am concerned about the reduction-----

I have been listening to the Deputy waffling for the past ten minutes. Which way is the wind blowing?

-----in the context of other charges facing people on foot of budget 2013. I refer, for example, to the increase from 50 cent to €1.50 in the prescription charge for medical card holders, as well as the increase in the threshold for the drugs payment scheme, a decrease in the amount available for the household benefits package and the introduction of a carbon tax on solid fuel, as well as the introduction of home tax.

Our senior citizens are being hammered with regard to these issues.

Overall, this legislation and the Government's health policy should be looking after the sick, the disabled and our senior citizens. This legislation does nothing for them. Once again, I call on the Minister to change his mind, to wake up, smell the coffee and stand up for our senior citizens.

I resent Members who laugh at a colleague when he is making a point on a serious issue like this one.

Deputy McGrath is laughing. He was play-acting.

The Government parties, which they were in opposition in the period from 2007 to 2010, made the same points to Fianna Fáil when that party imposed austerity on the people as those that are now being made to the Government. The then Deputy Jan O'Sullivan stated: "the-----

The Deputy is for nothing and against everything.

-----Labour Party will be vigorously opposing... [the medical card legislation] on all Stages." She said that in 2008.

The Deputy stands for nothing and is against everything.

The then Deputy also stated:

The granting of a legal right to a medical card to citizens when they reach the age of 70 was one of the few fruits of Ireland's recent prosperity that this age group was given. It gave them peace of mind and the chance to stay healthy and out of hospital.

She said that to take it away again was regressive, cruel and inhumane, and that it brought a huge outpouring of outrage onto the streets of Dublin. This was when Fianna Fáil attempted to take medical cards from our senior citizens.

The Minister of State also stated:

We owe it to [all] those who travelled from the four corners of Ireland to the Age Action meeting in... Westland Row, and to the... Senior Citizens Parliament demonstration outside Leinster House, to fight their cause in this democratic Chamber. [This is] ...a generation who paid their taxes at a rate that current young earners would find unbelievable. They saved their money for a rainy day. They did not allow themselves the luxuries of [changes of decor or foreign holidays]. [They made]... their own sandwiches and drank water from a tap or [even] a [spring] well. They richly deserved something back from the State.

The Minister of State further stated:

The Fianna Fáil-Progressive Democrats Government [in its wisdom] and credit to it for granting an automatic medical card to [all those] over the age of 70 in advance of the 2002 general election... It seems now that this was only granted for as long as it suited the Government [and the same applies to this Government]. When times got tough... [they were in the] first batch of cuts. This was done in a budget that [we were told was going to]... protect the vulnerable. On the contrary, the vulnerable are taking the brunt of the pain of these cutbacks.

She also said that in that context one had to question what was the intention into the future. She said: "The yearly review gives no guarantee [that more and more people] will not have the card removed in years to come." She quite rightly said that "the principle of universal access should be retained". She also said: "The Labour Party [has]... advocated a system of universal health care [since 2002], including free access to primary care for all citizens." She continued that we have a picture of what we could do for the health of the nation in the improved statistics in relation to older people since 2001, which is an important point.

The Minister of State added:

A study published in the Irish Medical Journal in 2004 showed that access to the medical card resulted in older people visiting their GP more often, an increased uptake of the influenza vaccine, a reduction in the percentage of people over the age of 70 who had a disability. It is not unreasonable to conclude that [this is the result of better] access to primary care and improved management of existing health conditions. There is strong evidence to suggest that men... [in particular had better] outcomes when they have medical cards [because without a card they would generally only visit the doctor when they are acutely ill rather than]... for regular check-ups and monitoring of conditions... It is quite feasible to suggest that there would be a saving to the overall health budget.

Those were the comments of the Minister of State, Deputy O'Sullivan, when in opposition when she attacked Fianna Fáil for attempting to cut people's entitlement to a medical card in 2008. It cannot be said by the Government that things were different then from what they are now. When the Government knocked on doors, it told people that it would protect the most vulnerable, those at the cutting edge and the coalface of HSE services, social welfare services and all those areas where people need support.

The Government is cutting the income limit for qualification from €600 per week to €500 for a single person over the age of 70 and to €900 for a couple who are living together. I have a question in this respect. Heretofore the income threshold for a couple was €1,400 per week and for a single person it was €700 and that threshold was dropped to €1,200 for a couple and to €600 for a single person. This Bill reduces the threshold for a single person to €500 and for a couple to €900. That is a big change to the income thresholds that have applied to date and it should be examined by the Minister. In saying that I want to make it clear that I am opposed to this Bill on the basis of its impact.

This issue will be extremely important for medical card holders. The Government wants to save €20 million on probity savings. I do not know what probity is for a person who seeks a medical card and needs one. Those who have a medical card will have a cut in their income of €144 per month if they have excess medical needs. If a person is earning over €184 per week, which is the medical card income threshold, that is less than most social welfare payments. The Government is saying to anybody in receipt of social welfare that if they are in receipt of more than €184 they are not entitled to a medical card. Following that logic, that will exclude a whole layer of people who are in receipt of jobseeker's benefit at €188, on pensions, disability benefit, etc. That is a huge anomaly.

Those in the medical cards section previously would have used discretion to give medical cards to people whose income of €188 or €190 was just over the threshold. The question is whether this change will be used as a way to say that people who were in receipt of a medical card are now not entitled to one. That is what is happening. This has happened to people who have contacted me and I am sure people have contacted other Deputies with similar cases.

I know of a young woman who worked in Blindcraft for many years. It was closed by the previous Government as it was selling the land in Drimnagh and this woman lost her job. She wanted to work; she was active in her community. She got up every morning and went to work in Blindcraft. When it closed she had no other option but to seek jobseeker's benefit and support from social welfare. For the past three years she has applied for a medical card because she has major underling illnesses and it has been refused every time. She has had to reapply for it and appeal the decision and she has got it. This year the same thing happened. She has been refused her card. We have sent her application back for a review and appeal and the medical card section has said that it does not know about it and that it has looked at everything, etc. Every year this woman has been refused her medical card and then given it. At each stage of the process she has been asked to give more medical evidence and more proof that she needs a medical card. The same proof has been sent in every year. Where does one get more proof if one is very ill and needs a medical card? This woman cannot afford the medication she is on if she does not have a medical card to support her. This is where this change is impacting on people. This is where the Government is trying to make €20 million in cuts. If that woman loses her medical card, she will have to pay the first €144 of the cost of any medication she needs. Therefore, she has taken a cut in her social welfare income of €144 per month. That is outrageous. This is a cut to people's social welfare income. The Government says that it is not touching core social welfare payments, but it is cutting everywhere else and this is affecting people's wages and income and people who are most in need of a medical card at a time when they are vulnerable. People are scared of their lives that they will lose their medical cards because of decisions made by the Government.

This Bill is a disgrace. The Government should lower its head in shame. It did not say to people on the doorsteps that it was going to cut people's medical cards. It is going to take €20 million out of the medical card system. The Government cannot say that it not going to affect people because some people will lose their medical cards. People who need cards are going to lose them. The Government should reverse its decision on this and not implement it. As I said earlier, we know there is money in this country. The wealthy are getting wealthier. Inequality is growing between those who have and those who have not in this country. It is a scandal that the Government, of which the Labour Party is a member, is implementing these cuts on ordinary people. I put it to the Government that this decision should be reversed and not implemented.

I really hope that Deputy Collins never assumes power because I would hate to see her in charge of any Department because she stands for nothing and is against everything. I am most disappointed with her contribution. Deputy Collins is like the fairy godmother sprinkling her wand here and there but no answers, no magic, only empty rhetoric. She will never have an answer to the question.

The wealth of the country-----

This Government spends €13.2 billion on health in a country of four plus million people. That is a fact, not fiction.


The Deputy is wrong and she should withdraw her remark that those who are entitled to a medical card will not get one. They will. The most vulnerable and those who need it the most will get a medical card. The Deputy is incorrect again. This is typical of the rhetoric in which she engages, time after time. Deputy Boyd Barrett and Deputy McGrath put their fingers in the air to see which way the wind is blowing. They are incapable of making a decision because they do not have the political courage to stand behind the Government in its decisions to get our country and finances back in order.

To cut medical cards. No.

Whether Deputy Collins likes it or not, the health system of our country is all about the people, the patient, the person who requires a service. That is my only motivation as a person, as a public representative and as chairman of the health committee. For too long we have heard the health vested interests shouting and roaring and using megaphone diplomacy when they should be coming into the middle ground. That includes the Members opposite who should come to the middle ground to put the patient first. For the first time we have a Minister who will put the patient first.

Some €20 million in cuts.

Fianna Fáil ran from the Department of Health under the Fianna Fáil-PD-Green Party Government because they could not take it. They were afraid of it. Deputy Micheál Martin ran with his hands up screaming and Brian Cowen called it Angola. These are the harsh facts.

The Minister is destroying it.

At a time of plenty, during the so-called Bertie Ahern Celtic tiger era, when money was thrown at everything, Fianna Fáil, the Green Party and the PDs, had to introduce Supplementary Estimates at a time of boom. Money does not solve everything.

During September 2013, 1.987 million people, 43% of the population have either a medical card or a GP-visit card. This is an increased number. Since this Government came to power, the number of medical cards has increased by more than 215,000. This is fact, not fiction. The number of GP-visit cards has increased by 3,344. This is fact, not fiction. When this Government came to office, 39.6% of the population had either a medical card or a GP-visit card but today that number is 43.35%.

Four hundred thousand people are unemployed.

The Government is creating 3,000 jobs per month and unemployment is decreasing. That is fact, not fiction. I know the Deputy will be disappointed because she wants the Government to fail so that she can propagate her message of doom and gloom again.

That is what the Deputy stands for. I will debate with her on any point.

Deputy Buttimer is obviously living in a bubble.

I live in the real world where I deal with people every day of the week. I welcome the fact that 93% of those aged over 70 will have a medical card or a GP-only card. I agree it is difficult to have probity with regard to medical cards. However, Members of this House are legislators and as such we must make difficult decisions in the interests of our nation, of our citizens and of our country. It is a case of responsible people framing policy and these decisions are not made in isolation but rather the basis for these decisions must be considered.

I refer to the Health Act 1970 which established the criteria for eligibility to access medical services. Section 45 provides:

A person in either of the following categories shall have full eligibility for the services under this Part---

(a) adult persons unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants,

The section also ensures that a person's overall financial situation is taken into account.

This is the current system and it is based upon income and hardship, that is, based on a means test and on discretion. We are all politicians and we meet people regularly. I remind Deputy Collins that we do not live in bubbles, we live in the real world. We realise that people need a system to be flexible and to exercise discretion rather than being rigid and inflexible. However, neither should eligibility be based solely on income because the health needs of individuals must be recognised at all times. As a society we should ask whether it is appropriate that outside of income assessment, the only other way to get full eligibility for health services is through the exercise of discretion. From what I can determine, there are very few clear guidelines as to how discretion is exercised. At times there is no clear rationale for decisions and no way to scrutinise decisions.

Why has the system been allowed to develop and continue? It can be traced back to fundamental characteristics of our political system, such as clientilism and patronage. One could go further and say that the system of discretion facilitated the wink and nod approach in political life. At one time, discretion created a situation where direct political influence could affect a decision and could put the deciding officers in the invidious position of exercising discretion over applications from people known to them. Discretion must always play a part in the awarding of medical cards, taking into account the totality of the situation in a household and the medical and social circumstances.

Administration of the medical card system has been centralised and the political element of the decision-making process has been removed while still allowing for that discretion which is now exercised in a central office by a medical officer but it is difficult to assess the exercise of that discretion. This uncertainty is also causing concern. I welcome the HSE's commitment given to Members at a briefing today and at the health committee that it will communicate clearly its decisions with regard to medical cards. The staff in the PCRS are working within the legislative guidelines and they are wonderful people, as are all our public servants working in the health sector. However, the centralised processing means there is one method and application of the rules for assessing eligibility which applies equally in Cork as in Donegal, in Wexford as in Tallaght. That is the way it should be. There is one uniform approach but it must be done humanely and with a degree of flexibility rather than being applied rigidly. When the system has moved away from the practice of political clientilism I ask whether the discretionary basis should be so wide. We should be considering a reform of the legislative basis of the system which is the Health Act 1970. Is it time to revise the criteria for making decisions? Should the Health Act be amended to allow for a clinical diagnosis to be a reason for accessing services? These changes pose difficulties and they cannot be implemented overnight but they would result in a fundamental change in how decisions are made and how access and entitlement are determined.

Members opposite who criticise the Minister for Health should take note that he is a reforming Minister who is prepared to take on the slow artic that is the Department of Health and the HSE in order to change the health services for the better. I describe it as being akin to turning a tanker which cannot be turned full circle in one manoeuvre. This Minister has been in office for two and a half years. He is turning the ship and he is getting there.

He is turning it the wrong way.

I remind the Deputy that his men ran away from it. They were happy to leave it to Mary Harney.

If Deputy Buttimer needs more time I can give him the discretion he is looking for.

I thank the Leas-Cheann Comhairle. I appreciate the discretion.

I acknowledge that people are worried but the underlying theme is that those who deserve and require access to health care by means of a medical card will be given it.

I refer to the long-term illness scheme.

I hope the Department and the HSE will engage with Age Action Ireland, the Carers Association and other organisations to remove the fear and confusion felt by people. Our elderly, in particular, deserve to be treated with respect when they ring the helpline or engage with the HSE.

There has been a 74% increase in the number of medical and GP cards since 2005. I welcome tomorrow's appearance by HSE officials before the Committee of Public Accounts to discuss the Comptroller and Auditor General's report on medical cards. I hope they will outline where and how medical cards are being awarded. The health sector is like an underlying volcano in this State and throughout the world. For example, America is convulsed regarding Obamacare and the new health exchange websites while other countries have similar problems with this sector. This is because it is about people who require access to health care. That is why as, the Minister said earlier, the budget and service plan for 2014 will be a challenge but let us put it in context. We have experienced, thankfully, a significant increase in the number of people living longer while more people are seeking treatment, services and facilities. While staff have engaged in health service reform, it is important to recognise that we have fewer resources and staff.

It is important that the Minister and the HSE differentiate between the voices lobbying and advocating on behalf of vested interests to keep the patient at the centre. I am all in favour of the unions and medical representative organisations lobbying and advocating as part of internal medical politics but the patient must be the core of what we do. If the Minister is asked by the HSE for more time to prepare for the publication of the service plan, he should grant that because it is important that next year's plan is focused on patient safety and ensuring people are seen in a timely manner, as he said earlier. If more time is needed, the Minister should afford the HSE that opportunity to compile the service plan.

While many of us disagree about elements of what is being done, there is no disagreement that access to medical cards on the basis of medical need must always be the way. While probity is welcome and necessary, at the same time it must also be about the patient and the need to access health care. Part of the problem is the Health Act 1970 does not confer an automatic entitlement to a medical card and that is why the discretionary element must be applied in the context of medical need. The health service is undergoing reform. I applaud the staff who work in the system and it is important that the health landscape continues to be patient-centred and patient-driven. We must consider the value of the medical card. John Hennessy made a good comment about the psychology of the medical card as opposed to the long-term illness scheme at the briefing earlier. We should debate the importance of the long-term illness scheme because we must communicate that to people. We have not done so at times.

Deputy Buttimer's contribution was interesting. It is a far cry from when he was on this side of the House calling for more money to be spent on health services. Obviously he has changed this tune in this regard. I have been told by many people that the Minister was a caring doctor for the elderly in his constituency but for some unknown reason he has changed his tune in the Department of Health. He does not seem to be able to protect the less well off and the elderly in our society. Over the past few years, prescription charges have increased while the bereavement grant and the telephone allowance have been abolished, DIRT tax increased and fuel allowance reduced. All these changes have had an effect on the elderly.

The Department is no longer in the control of the Minister and that is where the problem lies. It is controlled by the Departments of Public Expenditure and Reform and the Taoiseach, which the Minister more or less admitted at a recent health committee meeting. It is time he regained control of the Department and got on with dealing with health matters in the way they should be. The Title of the Bill sums everything up. Alteration means a reduction in the number of medical cards for elderly people. The legislation will result in 35,000 people losing their medical card over the coming year. This is in addition to the Bill passed last spring which hit more than 20,000 over 70s medical card holders. In total, 50,000 people will lose their medical card over the next year. The Minister said there would be a little discretion between now and January 2014 but that is only six weeks away and, therefore, people will not experience much discretion.

Many people attend or call my clinic because they are concerned that they will lose the card. Some of them will not but many will because of the change to the eligibility criteria. This is causing a great deal of concern and many people are frightened that they may lose their medical card. They are old and in poor health and the card gives them licence to attend a doctor without paying. Those who are slightly above the threshold will lose the card and they will have to pay for everything. In some cases, they will get a GP only card but that does not cover the cost of medication, which, depending on the ailment, can be high and can place a major financial burden on the elderly. The Government seems to have a serious dislike for older people given the various cuts it has introduced to their allowances over the past two years and they are causing a great deal of hardship and concern.

Deputy Buttimer touched on the discretionary medical card issue. There has been a major change in the way they are assessed. Up to nine months ago, a discretionary medical card application was dealt with quickly and was granted in most cases on the basis of medical need but that has changed significantly. It is taking months to have a card approved or rejected. When one makes an inquiry, one is told the application has been forwarded to the medical officer for a decision. Perhaps only one medical officer deals with the applications but there are huge delays. I dealt with a case where the consultant stated clearly in a letter that the person was in an end of life scenario but it took months to secure the medical card. That is not good enough. If a consultant's report states the person is seeking the medical card on discretionary grounds because it is an end of life situation, the card should be granted within a week or two at most but that is not happening currently.

That is causing serious problems and hardship for families and the Minister should investigate why it is taking the HSE so long to deal with such applications. It was always the case that if one was suffering from serious cancer, one automatically got a medical card but that is no longer the case. One must now battle with the HSE to try to get a medical card for a person suffering from cancer. It may be very severe cancer and sometimes one might only want that medical card for six or nine months or for one year, depending on whether one is cured or one passes on to one's eternal reward. The delays in issuing medical cards to cancer patients is a serious concern to many families because, as one knows, if one gets word one is suffering from cancer, it causes major gloom not only to the person who gets the message, but also to the family. There is a need to speed up the provision of medical cards to cancer patients.

We have had representations from the Jack and Jill Foundation and many other organisations stating that a considerable number of medical cards are being withdrawn from people with not very high incomes. These organisations represent people with spina bifida and Down's syndrome, for example. The Jack and Jill Foundation and many other organisations are at their wits end trying to provide services for their members. They could do without the hassle of trying to represent families whose medical cards have been withdrawn, despite the fact their incomes have not changed. These areas need serious attention. This change will cause serious problems for 50,000 families which will now lose their medical cards. It is an area the Minister should revisit. He is a general practitioner and should know the position of such families and how difficult it is for them when their medical cards are withdrawn.

I could read out what the Tánaiste, the Minister, the Taoiseach and many Fine Gael and Labour Party backbenchers said in 2008 when they accused the then Government of abandoning old people, even though the criteria for medical cards was a lot more generous than it is now. Now that they are in government, they have changed their tune and want to take more medical cards from such people.

The Minister should take back control of the Department of Health from the Minister for Public Reform and Expenditure and the Taoiseach because they now control the Department. The Minister has no say and he has been told he must cut €660 million. In the past couple of weeks, the Minister for Public Expenditure and Reform said he may have to cut another €1 billion. In all honesty, how can one run a health service when it is a case of making it up as one goes along without any hard and fast guidelines set down in the budget which was always the norm? The budget for every Department was decided on budget day but for some unknown reason that has not happened with the Department of Health and the Minister is trying to hide the fact he is no longer in control and that it is being run by two other Departments. That is certainly not in the interests of ordinary people who depend on the Department of Health and the HSE to provide adequate services for them. Will the Minister rescind this decision to withdraw medical cards from 50,000 people?

I concur with Deputy Browne's comments on some of the Government Deputies' contributions. I was here for Deputy Buttimer's contribution in which he lambasted previous Governments and sung the virtues of the current Government. It was markedly different from what people would have heard from Deputy Buttimer and others before the last election. It is remarkable how quickly some Deputies can sing a different song and play whatever tune is being called.

It is no harm to refresh our memories on what the Government committed to and the approach it said it would take in the context of its criticism of the last Government. Five years ago, the Minister for Health, who was the then Fine Gael health spokesperson and who was faced with a similar proposal from the then Government but with a much more generous eligibility criteria, fumed that those are the people who made this country what it is today, they raised us, nursed us when we were sick, protected us from violence, grew our food and ran a proud Civil Service and this decision is morally wrong and the people of the country know it. He stated - it is no harm to refresh our memories because we will not hear from the Government backbenchers what they told the people they would do if they got into government - that this decision was penny wise but pound foolish. The Minister also said at the time:

The Minister for Health and Children, Deputy Harney, told us that the annual cost of a medical card is €1,650. With the loss of their medical cards, many of those affected will attend their doctors less frequently than they should and 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.

At that time, the Taoiseach stated:

Elderly people do not want to be pressurised about means tests and application forms or have to worry about their property, their savings, what they have in the bank, whether a man from Government will call to their home or if they will lose their right to the medical card.

Many of us will recall the Taoiseach and the Tánaiste standing on a trailer outside the Dáil lambasting decisions made at that time and stating how they would protect medical cards and people over 70 if they were elected to Government. As Deputy Browne said, there is no end to the amount of commentary Deputies made at that time. I thought it was a bit rich to have to listen to Deputy Buttimer lambast Deputy Collins for a similar crime when he would have been singing an even louder tune no so long ago.

The Bill is entitled the Health (Alteration of Criteria and Eligibility) (No. 2) Bill 2013 because it is the second time in one year that the Government is reducing eligibility for people aged 70 years or over. In the first reduction in the eligibility criteria at the start of the year, 20,000 people over the age of 70 were removed from medical card eligibility. This Bill will hit one in ten people over the age of 70, or 35,000. It will bring the total number of people over 70 years of age who will lose their medical cards this year to 55,000.

There are other measures in the Bill which treat people over 70 years of age differently from those who are under it. For example, the over 70s eligibility criteria takes into account PRSI and income tax. It is based on the gross income of a person or a couple whereas allowances are made for those who are under 70 years of age. What we are finding with this second attack in one year is that many people, who are still eligible for a medical card and who are over 70 years of age, are rightly worried as to whether this time next year, they will find eligibility decreased further.

The impact of this measure on older people must be considered in the context of a budget that has been very sore for the elderly people as a whole. One of the features of recent budgets was that a conscious effort was made to try to protect the incomes, circumstances and quality of life of pensioners and the medical cards of people over the age of 70. In this budget, however, we have seen a conscious targeting of many of the payments that are made to people of pension age. The bereavement grant, which is claimed by many elderly people following the death of a loved one, has been withdrawn.

The hike in prescription charges will affect many people who have medical cards, particularly elderly people who tend to be on more medication than those who are younger. The Minister who is introducing this hike gave a commitment before the last general election to abolish the charge in question upon his election to Government. That commitment was in line with the comments of his party leadership and the commitments of many of his backbenchers in Dáil debates, as I have described. It is in contrast to what we have heard from Deputy Buttimer today. Rather than abolishing the prescription charge, the Minister is increasing it fivefold.

Some people will be particularly affected by having to pay the €2.50 prescription charge in respect of up to five items. I recently encountered the case of someone who is on a drug that used to be dispensed in 100 mg quantities. Following a reduction in the dose to 75 mg or 85 mg, that person is now paying the prescription charge three times rather than just once. That is because the drug now needs to be doled out in three separate amounts - one of 50 mg and two smaller amounts of approximately 15 mg. It was seen as one item but now it is seen as three items, which means there has been an increase of €7.50 a month. That certainly adds up in the case of a pensioner who is on a significant number of drugs. Some people are not able to absorb such an increase. Pensioners who live alone have particularly little room for manoeuvre because they are living on the breadline. Any cut or increase of this nature can have a significant impact on them. The level of DIRT charges on savings has been cut. The telephone allowance has been removed.

We need to bear in mind that those over the age of 70 are not the only people who are being targeted. Many people on discretionary medical cards are also losing out. We have heard many denials from the Government about the reality of the impact of these measures. Everybody who is involved in politics comes into contact on a daily basis with people who are suffering as a result of the Government's stealthy approach, which is gradually making it more difficult for people who received discretionary medical cards in the past to continue to receive them. It has resulted in the withdrawal of approximately 1,000 discretionary medical cards a month.

Overall, we are seeing a total lack of coherence on the part of the Government regarding what its health policy is about. There is no consistency between what it is implementing now and what it said in advance of the last general election that it would do. There is no link between what the Government is professing to try to achieve in relation to universal health insurance and what is happening on the ground. More people are losing medical cards. Medical cards are being withdrawn from the over 70s. It is becoming more difficult for those with discretionary medical cards to keep them. Thousands of people are leaving private health insurance. Some 62,000 people left private health insurance last year and it is estimated that 75,000 people might leave it this year.

I am disappointed with the measures and the approach being taken by the Government. People are looking to the Government parties to start to deliver on the rhetoric we heard from them in previous years. Unfortunately, many people are suffering as a result of things going backwards rather than progressing.

I would like to share time with Deputy Clare Daly.

Is that agreed? Agreed.

This country's senior citizens took a significant hit in the Health (Alteration of Criteria for Eligibility) Bill 2013, which we considered in March of this year. It is estimated that as a result of the enactment of that legislation, up to €12 million will be saved at the expense of vulnerable sections of our society. Statistics show that older people make more use of their medical cards than the general population. Figures indicate that 94% of people over the age of 70 visit their GPs on a regular basis. They have a high intake of drugs and medicine to help them cope with their above-average rate of illness and disability. The plight of these people and thousands of others will be exacerbated by the budget cuts and the measures in the Bill.

It is proposed to downgrade the medical cards of 35,000 people over the age of 70 to GP-only cards, to remove or restrict the cover offered to tens of thousands of people under the age of 70 and to clamp down on excessive prescribing and dispensing by doctors, dentists and pharmacists. This harsh initiative is designed to save a total of €138 million, some €25 million of which relates to over 70s and the other €113 million of which was categorised in the budget as relating to "medical card probity", which is a very vague term. Under the new thresholds for full medical card eligibility that will apply to the over 70s, a single person with a weekly income of over €500 or a couple with a weekly income of over €900 will lose their medical cards. Instead, they will get a GP card which merely entitles them to visit the doctor.

There is a glaring anomaly in the new eligibility criteria with regard to married couples over the age of 70. The new system for assessing applicants sets a limit of €500 for a single person. In the case of a married couple, the limit has been reduced to €900. I believe this discriminates on the grounds of marriage. It is probably illegal under the Equal Status Acts. Perhaps the Minister for Health should ask the Attorney General to review this. The question of whether this measure is illegal should be examined. Clarification should certainly be sought. I propose that the threshold for couples should be increased to the right amount of €1,000, rather than being set at €900.

The increase in the prescription charge to €2.50 per item will impose a significant additional burden on medical card holders, especially those who are on many forms of medication. Some people are on four or five medications for complex problems. Some of these people are in financial hardship, naturally. This increase will deter those who are finding it hard to make ends meet from going to get their prescriptions looked after and seeking the proper medicine. This certainly needs to be reviewed.

I would like to speak about eligibility for discretionary medical cards. The number of cards provided on the basis of discretion has decreased dramatically since 2010.

In 2010 some 80,500 qualified for these cards. Over the past three years this number has plummeted down to just 50,000. Discretionary cards based on financial hardship and exceptional medical needs have always been a feature of the medical card system. However, there is anecdotal evidence in abundance to suggest that discretionary medical cards are more difficult if not almost impossible to obtain and this has been the case in the past six months in particular.

The move to deprive non-terminal cancer sufferers of these cards is imposing further anguish and stress on these people. It is having a psychological impact if they are in danger of losing their medical cards when they also have to try to cope with their ongoing illnesses and in many cases deteriorating conditions.

In the past people with lifelong illnesses such as cystic fibrosis, multiple sclerosis, motor neuron disease, cerebral palsy and cancer were always granted discretionary medical cards on compassionate grounds. Now those who suffer with such conditions are asked repeatedly for information about their meagre income and their general means or assets. As a result the application process is very long and drawn out. Reviews are carried out and applicants may eventually be obliged to lodge appeals on the basis that they have a rapidly progressing illness. In the meantime their medical condition may have deteriorated further and may eventually prove terminal during that waiting time. Many things are not taken into account. The assessment for cards is very questionable particularly on the part of the medical people who are examining some really deserving cases.

Taking away the discretionary cards is not cost effective because it means that fewer patients can be cared for in their homes. In many cases they are becoming institutionalised prematurely. It is certainly leading them into hospital and institutional care much earlier than would be normal. To have a good quality of life these people desire to live in their own communities with the backup of their family and community care. While in their local environment they are much happier.

If the Bill is enacted I urge the Minister to ensure that future reviews of people who are under reassessment will be carried out in a sympathetic manner. Since the previous Health (Alteration of Criteria for Eligibility) Bill in March, the HSE has been extremely harsh and, I believe, irrational in its evaluations. In many cases it seems to be ignoring very valid further information regarding patients' medical conditions and financial hardships.

We should also be cognisant that these people are now burdened with overheads that are not taken into account in the normal assessment of need. For instance, we now have the local property tax, the abolition of the telephone allowance and cuts to the household benefits, and we will have the introduction of water charges. All these issues cause further deterioration in their living standards. We will need to change the assessment criteria to take account of all these matters which were not previously considered.

The cost of private health insurance is dramatically increasing for all age groups and this will also need to be noted in carrying out assessments.

The right to health is one of the most basic human rights that any citizen would aspire to. Our ability to access it is far too tied up with our ability to pay and the amount of money we have in our pockets. I have just come from a heart-breaking press conference of parents of much wanted children who were diagnosed with a fatal foetal abnormality. This afternoon they launched their petition to the United Nations regarding a violation of their human rights in this regard. One of the women, whose little girl was born in the summer with a number of serious health problems that require ongoing care and attention, made the point to me that in recent days they were denied access to a medical card. When people are already struggling to care for themselves and their loved ones, the idea of being dragged back down by financial considerations or bureaucracy is abhorrent in anything that would claim to be a civilised society.

In his opening remarks this morning, the Minister made the point that nobody who is entitled to a medical card will lose out through the changes in the legislation before us. I reject that way of putting things because it is possible to change the rules on anything to change people's entitlement. An entitlement is something in some ways that can be spun as being very different from saying that everybody who needs it will get it. Our starting point should be need rather than entitlement because entitlement introduces a certain element of an insult that some are entitled and others are not. Somebody who needs medical care should be entitled to access it regardless of financial means.

The problem here is that the goalposts are moving all the time. This legislation proposes to reduce the gross income ceiling for over 70s to get a medical card from €600 to €500 a week for a single person. It was previously €700 and in effect we are discussing the cumulative impact of a reduction of almost 30% in the past two years. As Deputy Tom Fleming stated, it is even worse for couples as they are experiencing a reduction of 35.71% over the two years. I believe the Minister has a social obligation to address the anomaly in this discrimination affecting couples. In any other scenario a couple is taken as having double the income of a single person.

However, not content with that in this scenario, the Government has reduced it to €900. Had it been double the single-person allowance as every other social welfare payment is and had the bar been set at €1,000, some people have informed me that they would still be able to access a medical card, but because of this sneaky manoeuvre they will lose out now. I know of at least one couple in my area and the wife in the relationship has a serious lifelong medical condition. They will not be able to access the medical care she needs through the GP and the medical card. She will probably end up in hospital and be a much more serious drain on the State.

What we are doing here is somewhat like our pension system and goes against the entire ethos of what the Government claims it is trying to do in terms of access to health care. The idea of universal payments is far more administratively efficient and far more equitable. When people are working and earning big money in their early or middle years, they should be taxed on that income. However, all citizens should be entitled to access medical care when they reach old age.

It is clear that this measure is designed to remove many people from that loop. We need to see it in the context of the living standards of pensioners. Much has been said about how they have not really been touched up to now, an analysis for which there is no backup. For 80% of our pensioners, the majority of their income comes from the State pension. That is a phenomenal figure. It is a very limited amount of money. When one gets to that age, one might not have a mortgage so one's outgoings are somewhat smaller, although many pensioners are obviously subbing their sons and daughters who cannot make ends meet. They are not living the high life by any means. Apart from an individual cost to the citizens, it will make people more cautious about their health care, leading them to slow down on measures that could get them an early intervention. It is inevitable that this will cost the State more in the long run. We are contributing to the undervaluing of elderly or retired citizens, which is a disgrace.

Other Deputies have highlighted the fact that regulations regarding gross income do not take into account the cost of those with special health needs and all the extra costs that go with managing particular health conditions, be it increased heating at home or the need to buy special food or maintain special medical equipment. We must see it alongside the other cutbacks like the second increase in the prescription charge from €1.50 to €2.50. It is just not good enough that the Minister for Health can say "vote for me and I'll abolish prescription charges" when he is an Opposition spokesperson and then increase them, not just once but twice, when he comes to power. This is an absolute betrayal of the electorate.

Medical cards are not a handout. The medical card is a benefit that was fought for and paid for by workers through the PAYE and PRSI they paid during their working lives. Withdrawing it at a time in their lives when they are most likely to need it is roundabout economics. In essence, it is an attempt to scapegoat elderly citizens as if they were the ones who caused the crisis because this is all about saving a few bob at their expense. When one considers the measures the Government failed to implement that would have allowed it to generate a considerable amount of extra taxation such as implementing a wealth tax, dealing with the issues of corporation tax and increasing the amounts of income tax on those earning six figure salaries, one can see that all of them would have enabled it to generate extra revenue. Instead, this Bill goes for the soft touch and will have an impact on well over 100,000 people in the community. Apart from prescription charges and other cutbacks, we need to look at the cutbacks in home help hours. We have short-term austerity measures that will cost society far more in the long term because we are not going to grant this concession.

I will deal briefly with the issues highlighted by many organisations that deal primarily with care for older citizens. In particular, Age Action Ireland has played an invaluable role in that regard. It has paid particular attention not just to this measure but to the cumulative and multiplier effect of rising costs and undermining health services as a combined product of the years of austerity and the financial pressure put on people. It must be seen in that context. Anne Dempsey from Age Action Ireland has said that "the ability to phone family and friends is an important link". She has also said that "this cut will drive people into further isolation, will contribute to greater stress on our health services and will ultimately cost more money than it will save". According to the second edition of Social Determinants of Health: The Solid Facts, published by the World Health Organization, "the longer people live in stressful economic and social circumstances, the greater the physiological wear and tear they suffer, and the less likely they are to enjoy a healthy old age". As one ages, the risks of health problems increases. The key issue here is that prevention is better than cure.

All of the measures we can put in place as a civilised society to raise the living standards of elderly citizens and allow them to access medical care when they need it, regardless of their ability to pay, not only deliver a healthier population but also save society far more money in the long run. To me, the Minister has got things completely the wrong way around. This is an austerity measure targeting the most vulnerable and will cost society in the long term.

Here again we find a Bill which contains measures that will drive another wedge between the Government and the citizen. It is another sundering of the social contract that exists between citizens and the State and the intergenerational relationship. This is a predictable and deliberate result of the Government's engagement in the politics of division. It has encouraged different groups within society to turn upon one another. We now have a situation where the most socially divisive economic policies have emerged and it is now a case of public verses private sector, employed verses unemployed, able versus disabled and urban versus rural. The Minister is delighted to have a situation where people are at each other's throats, where there is insufficient opposition to this Government and where social cohesion is on its knees. If people are at each other's throats, they are not effectively opposing the Government. It is called social solidarity and was already weakened as a consequence of the excesses of the Celtic tiger years. Certainly this Bill sets out to kill off the remnants of social solidarity. It is a sad loss to think that this is the result of efforts by this Government because I see a value in social solidarity and believe it will be essential to our recovery, not just in economic terms but, more important, in social terms.

The Government has sown the seeds of discord. Groups are squabbling and competing and the Government is effectively picking them off one by one. It can continue to try to pull this trick to protect the powerful vested interests within our society and many of those outside of it. These vested interests include the legal profession, the banking sector, the international bondholders, the medical drug companies, large corporations and senior civil and public servants, including Government Ministers. The list goes on. This budget has shielded these classes from the worst effects of our current difficulties. From the failure to reform the legal services to the failure to secure saving in the medication bills for the health service, the Government has shown a marked reluctance to engage in reform that threatens those with the capacity and resources to resist it. Labour Ministers expended much hot air after last year's budget boasting of the wealth taxes they brought in. Those wealth taxes have yielded far less than had been anticipated and it is clear that the elderly and other groups must make up the difference. The thought that the Government might go back and make an effort to reclaim what it failed to gain in taxes from the wealthy does not appear to have occurred to the Minister.

This Bill attacks that which matters most to our elderly people - security in old age. With the cost of medical insurance escalating and the Finance Bill ensuring it will escalate further, many elderly people are left fearful about how they will pay their medical costs at a time in their lives when such care becomes a great concern. This Bill will leave many more facing into that uncertainty with their best friend - fear. My clinics are filled with senior citizens worried about their future medical care.

This Bill continues the odd disparity between the limits for a couple and for two single people. There seems to be some idea that people can seek efficiencies in their respective and usually different medical complaints. Previous speakers have raised this issue.

It is as if the Minister believes that a husband suffering from cancer and a wife suffering with osteoporosis can somehow seek savings in the treatment of their complaints simply by virtue of being a couple. It is nonsense. There is no fair case for a couple having a lower income limit than that of two single people.

The Bill cannot be seen in isolation. It is one of several attacks on the elderly being made by the Government. Prescription charges have been mentioned. They have been increased and that is causing grave difficulty for senior citizens. We know this because the Minister informed us of it during his time on the Opposition benches. The Government has cut the telephone allowance, increased the deposit interest retention tax, DIRT, raided their pensions and attacked their security. It has also abolished the bereavement grant, which has left many senior citizens upset that they or their spouse will have to pay funeral costs.

The Government has been pushed to such measures by the dawning awareness that their economic policies are simply not working. The growth the Government has consistently promised has failed to materialise. When the previous Government attempted to cut medical cards to the elderly, many of those now on the Government benches stood outside this building and lacerated it for doing that. They engaged in high-blown rhetoric about the debt owed to the generation that fought the civil rights campaigns, yet when the time came for them to be tested on their virtue, they failed. They talked the talk but, lamentably and unsurprisingly, failed to walk the walk.

Underlying much of this attitude towards the elderly in our society is a view in the Government that elderly people are a cost and a burden. The Minister for Health only recently blamed the overspend in his Department not on his own maladministration, but on the phenomenon, hitherto unnoticed by him, of people getting older and living longer. The aged are to blame for the condition of our health services because they have the temerity to live longer. A nasty language is deployed by this Government, such as the term "bed blockers", which is a sign of a failure to recognise the inherent value and dignity of those people who are entitled to services in this country. Being a productive member of society has been reduced to meaning only those who work and pay taxes. Other forms of contribution go unrecognised and gratitude for past contributions, even in a lifetime of difficult times, is non-existent.

Some might say that this is simply Fine Gael reverting to its natural instincts in its politics, but the Labour Party at least claims to aspire to a higher ideal. Every year the Labour Party pays homage to the ghost of Tom Johnson, the second leader of that party. He was one of the authors of the Democratic Programme of the first Dáil and it is from that document the following quote is taken: "The Irish Republic fully realises the necessity of abolishing the present odious, degrading and foreign Poor Law System, substituting therefor a sympathetic native scheme for the care of the Nation's aged and infirm, who shall not be regarded as a burden, but rather entitled to the Nation's gratitude and consideration."

The aged should never be regarded as a burden in our society. They are due the nation's gratitude and consideration. I would argue, and some who preceded me have argued, that this is a noble ideal which was recognised by many former members of the Labour Party who have now attained high office. In a speech in this House in January 2009 a particular Labour Party Minister described the Democratic Programme as a vision of possibility and as constituting "the minimum demand for Labour's participation in Government". We all know the reality of that. The Labour Party has lacked the courage of its convictions and has failed the old, the young and women and left those on the margins of our society isolated.

This Bill represents yet another nail in Tom Johnson's coffin. I can only hope that the Labour Party might at least have the decency to let the spirit of this man rest in peace and take his name from the summer school it uses every year until it once again finds the courage to stand up for what it professes so earnestly to believe in the Democratic Programme.

I am glad to have the opportunity to speak in this debate. It is notable that the Government is not offering any speakers at this point. Apart from a handful of Members who had the courage to show up at the start of the debate, it appears no other Government Members are offering to speak. That speaks volumes about this Government's position and all the promises that were made over recent years. When it comes to a decision on this issue, nobody has the courage to show up here today and provide any type of defence for this legislation. It is no surprise, because it is indefensible legislation. The Government Deputies in their offices might be running scared but the electorate knows who is responsible for these vicious cuts.

Given the fact that there are three Ministers in the Department of Health, it is also disappointing that they are unable to attend this debate today. Other Ministers and Ministers of State are being sent into the Chamber to cover for them. The least they could do is come into the House and defend the cuts contained in this legislation.

What we have seen as a result of the budget is an utter lack of coherence in the Government's health policy. It is now in total disarray. The provisions of the programme for Government set out a clear plan for fundamental reform of the health service by switching the focus away from hospitals to primary care, through opening up access to GP care and enhancing primary care services to make them fit for purpose so they can genuinely meet 90% of people's health needs, which we were told was the intention. It is clear that policy is in disarray. There is no commitment to the type of fundamental reforms that are required. What we are seeing now is merely an attempt to chase the recurring deficit in the health area. Nobody has got on top of the financial situation in the Department of Health. Nobody has reined in expenditure and dealt with the underlying cost drivers in the Department, such as the ridiculous pharmaceutical bill and other huge costs that must be tackled. We are not seeing reform and matters can only go from bad to worse at this stage, given the financial circumstances and the lack of reform in the early years of the Government's term of office.

We were promised wider access to primary care, but we are getting the opposite. In the budget, a great deal of attention is focused on the initiative which is due to be implemented at some point later next year to provide free GP care for children aged five years and under. The Government is making €37 million available next year for that initiative, but it is giving with one hand and taking with the other because, on the other hand, it is targeting savings of €149 million from the medical card scheme. The impact of that will be extremely severe on tens of thousands of people. One category of people that will be severely impacted by this savings target is the category under consideration in this legislation. The legislation seeks to further restrict access to medical cards for people over 70 years old. This has caused a great deal of concern among older people.

Other speakers have quoted comments by the Minister for Health when he was in opposition. The actions he is taking now are clearly a direct contradiction of all the claims he made in earlier times. Some 35,000 people over 70 years of age will lose their medical cards as a result of this legislation. There are three very distinct aspects to that. The first aspect we must bear in mind is that in the case of people over 70 years old we are talking about gross income.

It is not possible to have disregards, irrespective of one's medical or living expenses. The type of disregards that are allowed for people aged under 70 years are not allowed for those aged over 70 years. We are discussing gross income, which changes the picture significantly.

My second point is probably of most concern to older people. Not only does a medical card provide access to general practitioner, GP, services, but also to other essential community primary care services, for example, home help, public health nursing and physiotherapy, that older people need. The withdrawal of the medical card in respect of those 35,000 people will see them losing that access. As people move into their 70s and 80s, the need for these services becomes all the greater. In many areas, it is not possible to access them. Leaving aside financial considerations, such services are not available privately. A more nuanced approach was necessary. Even a system of co-payments would have been preferable in order that people might retain access to essential primary care services.

My third point is on the distinction in treatment between two people living together as siblings or friends and two people who are married. We are moving away from individualisation, in that the allowance for a couple is less than the allowance for two siblings living together. There can be no justification for this. There are grounds for a case to be taken against the distinction.

This is only one way in which medical cards will be restricted. A second matter of concern, one that has received little attention since the budget, is the targeted savings of €11 million as regards people who have recently returned to work. We all know the difficulties posed by the disincentives to taking up employment, but a measure that assisted people in moving from long-term unemployment into employment was the ability to retain their medical cards. This measure is to be removed. We have heard a great deal of bleating from Fine Gael backbenchers, complaining to the Minister for Social Protection, Deputy Burton, about people not being incentivised to return to work. This measure allowed people to return to work, as they could retain their medical cards for three years. Under this budget, however, that concession has been withdrawn. It is a slap in the face for people who recently took up work, as the withdrawal does not apply to new entrants alone. We have been told through replies to parliamentary questions that people who are still in the three year phase after returning to work will have their medical cards removed and will be means tested. This is a particularly mean measure. There are also tax implications for people in such circumstances, as holding a medical card allowed one further concessions.

The main issue is the targeting of €113 million in savings from medical cards. It is all very well for Ministers to react to this move and to try to reassure people that no one with an entitlement will lose a medical card, but if the budget has targeted savings of €113 million, either large numbers of people will lose their cards through a tightening up of the assessment of means and other conditions or the savings target will not be met. Either way, it is a dire situation for people who are dependent on the public health service. Next year, tens of thousands of people will lose their medical cards or savings will not be made, leaving a hole in the budget that will need to be filled by achieving savings in front-line services. It is a poor look out for people who depend on the health service. It is clear that Government health policy is in disarray.

I will step aside from the detail of this Bill because so much has been stated by other Deputies. Instead, I will take a step back to 9 March 2011, the day this Dáil convened. I will quote Deputy Enda Kenny's 2 p.m. acceptance speech on his nomination as Taoiseach. He stated:

I am mindful of the task we begin, that of rescuing our economy, resuscitating our reputation and restoring our society. Also, because we stand on the threshold of fundamental change ... I do not say this to be negative or excusing but to be real and true, to tell the truth of the Ireland of today ... That our lives and futures are predicated on one thing is true. That is why today I enter into a covenant with the Irish people. In these times of crisis, full of many unknowns, honesty is not alone our best policy but our only policy. The new Government will tell the people the truth regardless of how unwelcome or difficult that might be. We will tell it constantly and unreservedly. It is the only way because the people always have a right to know. I use the word "covenant" over "pledge" and "promise" because I believe the old ways of politics damaged us not alone financially, but emotionally, psychologically and spiritually. The word "covenant" restores a sense of heart, soul and spirit to leadership and our shared national life ... Our programme for Government is ambitious, fair and truly radical. [Where is the evidence of this?] The Government and the people, working hard and side by side in each other's interests, will achieve their objectives and because no party has a monopoly on good ideas, we will, in the spirit of inclusiveness and generosity which we want to bring to this Dáil and our Republic, collaborate and work wherever and whenever possible with Members of the Opposition in the interests of our country and people. [Where is the evidence of this?]

This is our country. This is our journey. Yes, we are in times without precedent but I believe that for Ireland this current crisis is the darkest hour before the dawn, that we have a generational lightness of soul, that in the long Hibernian nights on the western edge of Europe we remembered the light that went before, imagined the light to come. We are a people looking always and ever to the possibilities of a new day. That new day is here, a bright new day where there is no gap, where the people and its Government are one again, a day when our people are united in cause. Seamus Heaney said: "You have to try to make sense of what comes, remember everything and keep your head." We will. Together and for our country let us believe in our future. For Ireland and each other, let us lift up our heads, turn our faces to the sun and, as has been already said, hang out our brightest colours. This is the first day of a journey to a better future. That future will be achievable when Ireland can again take charge of its own destiny, when by the centenary of the 1916 Rising we can prove to be the best small country in the world in which to do business, to raise a family and to grow old with dignity and respect.

Budget 2014 does nothing to put the Taoiseach's last four lines into reality. The evidence is that our society has become more polarised. An article by Vincent Browne in today's edition of The Irish Times shows how "Love/Hate", the programme everyone is talking about, is an expression - at one level only - of great hurt in our society.

The establishment is where the levers of power and influence reside. There has not been a fair distribution and sharing of the country's resources. Corporate taxation has got off too lightly. Despite there being €70 billion in profits among companies, mainly in the multinational corporation and foreign direct investment, FDI, categories, only €4 billion has been paid in taxes. This represents an effective rate of 6.5%, not 12.5%. Someone might claim that reported profits are different from tax assessable profits, but it is the companies that are reporting these profits.

If that is what they say they are earning, that is what they should be taxed on. It is simple but we allow ourselves to be confused by the experts. Earlier today, the Taoiseach dismissed the idea of experts but the Government has had its preferred and highly paid experts. We can number them on the fingers of one hand or maybe two and they have received millions in fees. They are the only experts that seem to have a monopoly of wisdom and insight.

People in their seventies and older deserve respect; they deserve to be embraced. Corporations and companies who profited from their work should be paying society the necessary resources to look after such people's needs.

I will speak to the specifics of the Bill shortly but, first, I wish to comment on the Government's supposed vision for health care. The Minister will know that we had our reservations to begin with, to put it mildly. We never truly believed that reliance on the private insurance sector, itself enfeebled and in many respects subsidised by the public system, could ever truly deliver the type of care that citizens should be entitled to as of right.

However, even if we were to take the Government at its word, we now seem to be a long way from the programme for Government which was published in 2011. The programme for Government states:

This Government is the first in the history of the State that is committed to developing a universal, single-tier health service, which guarantees access to medical care based on need, not income. By reforming our model of delivering health care so that more care is delivered in the community, and by reforming how we pay for health care through universal health insurance, we can reduce the cost of achieving the best health outcomes for our citizens and end the unfair, unequal and inefficient two-tier health system.

Realising a vision is not easy. I accept that it requires preparation, planning, co-operation, compromise and time. We are more than two and a half years into the life of this Government - closer to the next election than the last - yet we are as far as ever from this vision. For every step forward, such as free GP care for under fives, we see two steps back, removing so-called discretionary medical cards from so many who desperately need them and, for the second time, making a raid on medical cards for the elderly.

Many of the Government's original commitments have seen no progress whatsoever. The programme for Government says that universal primary care will remove fees for GP care and will be introduced within this Government's term of office. We were told that 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 €17 million. We were led to believe that access to primary care without fees would be extended in the second year to claimants of free drugs under the high-tech drugs scheme at a cost of €15 million, and that access to subsidised care would be extended to all in the next phase. The final phase would see everyone having access to free primary care.

The Government's rhetoric on primary care is good. Primary care is an area where we have lagged behind other parts of Europe and there is a need for investment now, which will accrue savings in the long run. The delivery of some primary care centres is a positive move, but it is far from being enough. As regards the extension of actual primary care, we have not made any real progress as regards these policies whatsoever.

At this rate, it is hard to imagine the goal of universal health care, with an end to the two-tier system, being delivered in the life-time of this Government. It is hard not to wonder whether the next 12 months will not in fact see a deterioration in our health care system and the quality of health care delivered.

At the time of the budget, as with every year, we saw Government TDs briefly and furiously spinning the budget as one which protected the most vulnerable in our society. For the most part, remarkably, many of them seemed to believe it. However, even the most enthusiastic Government TDs appeared overcome with reticence and doubt when the €666 million in health cuts was brought up. The sum of €666 million is an ominous and enormous number. The big question is what these cuts will amount to. Anyone can recognise that such a huge sum can hardly be removed without doing some damage.

We have begun to see what it will mean and this legislation is part of that. For the second time in 12 months, the Government is going for the elderly and removing cards from approximately 35,000 people in that age category. Gross weekly income limits will drop from €600 to €500 for a single person and from €1,200 to €900 per couple, which is a substantial drop.

My colleague, Deputy Ó Caoláin, has ably demonstrated how the Minister has jumped from one position to the next on income limits. In particular, the Minister will recall his own comments at the time of the Fianna Fáil changes to income limits, when he said that "tinkering with income limits is nowhere near good enough" and that the cutbacks were "a vicious assault on the elderly". It appears as though his opinions on such matters, far from being guided by any commitment to a vision, are guided by what position or office he holds.

We are talking about a category of people who are far more statistically likely to need their medical cards than others are. This is not only a false economy, it is grossly unfair and yet another attack on the elderly who were already badly hit in the budget. I note in particular the cynical abolition of the phone allowance.

The Minister has sought savings of some €149 million to the medical card scheme. It is a precise figure coming under the heading of medical card probity, which is a mysterious and vague heading. Probity seems to infer some form of wrong-doing or deception on the part of those who have medical cards that the Department has decided no longer need them, and that there is a lack of probity on the part of those in possession of such cards.

We are seeing people with disabilities, with life-limiting diseases and the elderly, all losing cards. I have referenced examples in this house, as have others, of people with life-limiting diseases and serious chronic diseases, being denied medical cards when quite clearly they need them. The Minister's demanded savings will obviously result in suffering, hardship and pain. People who need medical cards will lose them and of that there is no doubt.

We will also likely be looking at seriously curtailed service plans in the new year, as CEOs and hospital management around the country are faced with budgets they simply cannot manage with. We have already had a glimpse of what that might mean in a letter from the CEOs of Crumlin, the Mater, St. James's and Tallaght hospitals, claiming that cuts to their budgets in recent years have led to delays for the treatment of cancer patients.

One of the leading oncologists in Our Lady's Children's Hospital in Crumlin said that delays experienced by children being treated for cancer are "unacceptable". I fear that this is only the tip of the iceberg and that we will see further delays in treatments, as well as cutbacks and reductions in services. There is no way such a sum can come from our hospitals and for them not to suffer. The reality is that our hospitals are underfunded. The Minister will point to the free GP cards for under fives, which are welcome indeed. However, in terms of what is being taken away, it does not go anywhere near to making up for it.

Sinn Féin produced a pre-budget submission which included free GP cards for children under five without undermining the quality of care for other citizens. While some children get free GP cards, and that is welcome, their seriously ill siblings or their grandparents might be losing them at the same time. What part of this resembles universal health care and how can this possibly be in accord with the Minister's vision?

Under the Minister's proposals and policies, many in desperate need of care are having their ability to access it reduced. This is a long way from what the programme for Government promised, which was universal care based on need, not the ability to pay. On the one hand, it asserts the importance of universality. On the other hand, however, with legislation like this, it attacks what were universal entitlements in the form of these medical cards. The Minister has lost direction and this Government's supposed vision for health care reform is a long way from being delivered.

Deputy Robert Troy is sharing five minutes of his time with Deputy Seamus Kirk and ten minutes with Deputy Barry Cowen. Is that agreed? Agreed.

I welcome the opportunity to contribute to the Second Stage debate on the Health (Alteration of Criteria for Eligibility) (No. 2) Bill 2013. What a nice PR savvy title for legislation. This legislation provides for a serious reduction in the number of people eligible for a medical card. It seeks the withdrawal from entitlement to a medical card of 35,000 people over the age of 70. Simply put, this legislation is a deplorable betrayal of our senior citizens and of the men and women who fought hard for the country in which we live today.

The irony of the Taoiseach's statement today in the context of a further hike in the cost of health insurance that it was necessary to protect older people while we are discussing legislation that will ensure that 35,000 of them will no longer be eligible for a medical card or GP visit card will not be lost on the people. This legislation provides that the income limit for an over 70s medical card for a single person will be €500 per week and for a couple will be €900 per week.

The Minister, Deputy Reilly, when Fine Gael Opposition spokesperson on health, said:

Dáil Éireann demands the immediate reversal of the Government's decision to withdraw the automatic entitlement to a medical card from citizens aged over 70. This decision is penny wise and pound foolish.

That is what he had to say at a time when income limits were much more generous than are provided for in this legislation.

On discretionary medical cards, the Taoiseach and Minister for Health have suggested there will be no change in the eligibility criteria for discretionary medical cards yet savings in the region of €120 million are to be made in this area. How is it possible to secure savings of €120 million if there is to be no change to the eligibility criteria or reduction in the number of people who can avail of discretionary cards? During the first nine months of this year on average 1,154 fewer discretionary medical cards were issued each month. What the Government is saying does not add up. Discretionary cards are awarded to people with chronic and serious illnesses, which illnesses are being compounded by this Government's policies. This Government's policies are having a negative impact on people granted discretionary medical cards based on illness. I will give two examples, the first of which was referred to when we previously discussed this issue. A young girl from my constituency who is over five years of age and as such does not quality for free GP care services, is fed through a peg in her stomach and has received in excess of 40 injections into her stomach had her discretionary medical card withdrawn despite her mother providing the HSE with further medical evidence to support her case, which decision was reversed following the issue being highlighted by her mother on Joe Duffy's "Liveline" programme. The second case involved a man over 70 years of age who was approved for a medical card in September only to have his eligibility reviewed in October.

It is obvious there are major administrative problems within the HSE medical card section which need to be addressed. The Government should first try to address the administrative problems in the system before withdrawing medical cards from 35,000 senior citizens. This Bill should be titled what it is, namely, a grab on our senior citizens once again.

I welcome the opportunity to contribute briefly to the Second Stage debate on the Health (Alteration of Criteria for Eligibility) (No. 2) Bill 2013. The purpose of the Bill is to amend the Health Act 1970, as amended, to change the eligibility rules for medical cards for persons aged 70 years and over. The legislation will come into operation immediately on enactment.

The Bill sets the gross income limit for assessment for an over 70s medical card from 1 January 2014 at €500 per week in the case of a single person and €900 per week for a couple. Cuts in relation to medical cards for the over 70s is an appalling betrayal of people in that age category. The move by the Minister, Deputy Reilly, to restrict eligibility to the over 70s medical card is a shameless betrayal of their position. Some 35,000 people over 70 are being betrayed by the Government. The Minister, Deputy Reilly, is robbing grandparents to give free GP care to their grandchildren.

Dr. Ray Walley of the Irish Medical Organisation stated:

I fear widespread chaos over the coming months as the HSE start their 'purge' of medical cards on foot of the Budget directions. This is a question of priorities and in health we have to focus scarce resources on those who need our help most.

I agree with that statement. This move is negative, counterproductive and impacts the elderly, the people who have shaped and created our nation. This is unfair and it should not and will not be tolerated.

In recent weeks, I have been contacted by a number of constituents who are concerned about the implications for them of this legislation. Under budget 2014 medical cards will be withdrawn from 35,000 people over 70. That is an official estimate from the Department of Health. As such, in the region of one in ten over 70 medical card holders will be affected. It must be remembered that this reduction comes on top of the removal of 20,000 over 70 medical cards under budget 2013. At that time the Department of Health estimated 360,000 people aged over 70 held medical cards. The fact is that over two budgets medical cards will have been withdrawn from approximately 55,000 people aged over 70. To say that approximately 11,000 or 3% of people have been impacted is simply not true.

Where is the fairness about which the Minister continually speaks? This Bill is not fair: it is wrong, pure and simple. This legislation will bring 150,000 people over the income limit and while they are still set to receive free GP care, they will have to pay for prescription medication. In July 2013, the number of individuals eligible for a medical card in circumstances where the HSE exercised some element of discretion was 56,245 as compared to 80,524 at the start of 2011. Is this cull of 24,279 over two and a half years just the start? What is coming next?

In its last election manifesto, Fine Gael, in terms of its new vision for the country, promised to introduce better care services. In relation to terminal illnesses and medical cards, Fine Gael said it would expedite the medical card application process for people with terminal illnesses and would also consider abandoning the medical card means test for people with terminal illnesses. This has not been done.

I spoke on a Topical Issue matter a few months back and the Minister of State, Deputy Lynch, responded as follows:

Under the legislation, there is provision for discretion by the HSE to grant a medical card where a person's income exceeds the income guidelines. The HSE takes a person's social and medical issues into account in determining whether "undue hardship" exists for a person in providing a health service for himself or herself or his or her dependants.

This is not fair. This is unjust and wrong. What are the Minister of State's thoughts for the 150,000 people who will suffer the impact of this? We must look at the human element rather than the overall figure of cuts, cuts and more cuts. People's lives will be affected. The role of a Deputy is to protect and serve the people. That is what we are trying to do today. There needs to be change so that these cuts will not go through.

The Irish Cancer Society states that a cancer diagnosis can have a significant adverse financial impact on patients and their families in Ireland. That is a serious matter for consideration by the Minister of State.

We live in very difficult times. This Dáil was convened in very difficult and constrained times. The period of fiscal rectitude over the last few years continues to be difficult, disconcerting, at times horrific, unnatural and unnerving. I could go on with different adjectives to describe the effects. Those adjectives would be descriptive of the various sectors, depending on the cohort and one's place in the economy. It depends on whether one is employed, unemployed, self-employed, employed in the private or public sector; disabled or not disabled; married or not; is a student, a graduate or a postgraduate; and on whether one is dependent or not dependent, or sick or not. Irrespective of whom or what category, all those mentioned are being severely affected, some to the extent that they have lost jobs, lost or fear losing homes, lost pensions or savings, entitlements and businesses, not to mention self-esteem. Many have left our shores and distort the figures that some Ministers proudly quote in respect of unemployment.

This process, along with the associated hardship and pain, has been horribly difficult. The predicament has straddled two governments and has placed great strain on the State's ability to deal with its effects, particularly in the area of social protection and in health. It obviously places strain, pressure and a particular obligation on those with leadership roles, such as those who head up Departments, as they have to respond appropriately, fairly, effectively and honestly. That response must have fairness at its core and it must seek to bring the people with it, instill a resilience in the people and to strive to plot a path out of our difficult times.

Having been faced with financial calamity, the previous Government was obliged to provide capital to maintain proper and functional governance. Irrespective of the national or international factors that brought us to that point, such funding from the troika would raise far less than would have been raised if the open markets were available. However, it allowed us to plot a means by which we might arrive at a pathway out from that point. The conditions attached to the funding were obviously challenging. Adjustments had to be adhered to. The gap between income and expenditure, irrespective of the funding sources, had to be bridged. The fiscal adjustments were severe, but most of us now recognise that they were necessary and the process has continued.

The Taoiseach was very excited and proud of himself and his own role in the impending exit from the bailout on 15 December. It needs to be said that this exit was pencilled in long before he came into his esteemed office. While he lauds that process, he should own up to the many Damascus moments he had along the way. He can point to success on interest rate adjustments. He can say that economic indicators are better, but the manner in which he met those difficult targets and the manner in which his Government continues to meet them, the choices his Government makes, the effect of its budgets and the adjudication of those budgets by an independent source such as the ESRI, means that all this is described as regressive, not progressive. The Government, the Taoiseach and the Minister for Health rubbished the fiscal policy of the previous Government when it sought to close the gap between income and expenditure by substantially greater amounts than that targeted in the last two budgets by this Government. The budgets introduced by that Government were adjudicated by the ESRI to be progressive.

In the election campaign of 2011, the members of the current Government said that they would do things differently. They would be more fair. They would find an easier way, a softer way, and a way in which to honour all the commitments that they had made to various sectors throughout their period in opposition. It did not matter whether it was Deputy Enda Kenny or Deputy Eamon Gilmore standing here, they said there was an easier and softer way to fill the huge gap that existed, and they were still going to accommodate the promises and commitments that they made to the electorate. They said they would burn bondholders. As I said here one day, they would not burn a sod of turf. They said they would retain social welfare rates. Ask mothers and families if have they done that. Ask young people on jobseeker's allowance if they have done it. Ask carers and the disabled.

They said they would protect income tax rates. Ask pension contributors if they have done that. Ask single parents if they have it. Ask home owners paying property tax. Ask home owners who are faced with water charges for a system that seemingly will not be fit for purpose.

The Minister for Health, when in opposition on these benches, said time and again that he would honour this country with a universal health system. Let him or the Minister of State here this evening ask discretionary medical card holders if he or his Government have done this. Let him or the Minister of State ask those aged over 70 who have lost their medical cards if they have done it. Ask people who were promised an end to prescription charges. Ask people who have had their home help hours cut. Ask the elderly who had their fuel allowance cut in the previous budget. Ask people who had their electricity allowance cut in the previous budget. Ask people who had their telephone allowance taken in this budget.

This Bill is symptomatic of this Government's ability to plough on regardless and achieve the targets set by the last Government in a way in which this Government sees fit, irrespective of the commitments that it made to the electorate in 2011. The Government ploughs on at the expense of the most vulnerable, the most needy, the most exposed, and at the expense of those who were described by the Minister for Health himself as people who made this country - those who raised him and the rest of us, who nursed us and protected us. What protection has he given to the same people in favour of whom he spoke so proudly back then?

The Minister of State and his Government stated in 2011 that they would achieve their targets in a way that would not curtail our health service, and in a way which would not affect the sick, the vulnerable, the needy and the poorest.

The promises the Minister made in this area and others were made to an electorate open to such commitments and promises and to fiscal rectitude by different means. To paraphrase a Cabinet and party colleague of the Minister of State, the promises and commitments that the Government made to the electorate at a time when our country was in such a perilous and vulnerable state were a sort of economic treason. It rests on the shoulders of those who made those predictions when they knew quite honestly that they could not keep them. They were made well aware at every possible opportunity of the difficulties that would befriend them when they came into office in order that they could address the problems that had to be dealt with. I do not say this lightly but it was said very flippantly on the other side of the House on a certain occasion and it is coming back to hit the Government twice as hard.

I welcome the opportunity to speak on the Health (Alteration of Criteria for Eligibility) (No.2) Bill 2013, which seeks to give legislative effect to the changes to medical card eligibility for over 70s as advanced in the budget of 2014. This was a savage budget, which, through stealth, hit at the pockets of some of the most vulnerable individuals in our society and specifically targeted the elderly. This is clearly evident in the measures before the House which drastically reduce the income limits for assessment for an over 70s medical card. It is estimated that as a direct result of this decision by the Government, one in ten pensioners will lose their medical cards.

To put this in context, more than 25,000 pensioners will face life with no medical card and it is anticipated that more than 2,000 Tipperary medical card holders will lose out. This is at a time when statistically a large portion of those over 70 will have serious health issues and high care needs. It is contradictory to remove means-tested cards from a section of society which has high medical needs in a budget which is rolling out free GP care for children, irrespective of the income of their parents. Surely this sector of society, which is recognised as having specific and increasing care and health needs, should be protected rather than attacked and should be a priority? This is a cruel, unfair and mean-spirited cut that has led to a wave of anxiety and will have a devastating effect on the peace of mind of older people. The elderly in society cherish medical cards. A medical card serves as a reassurance, a safety net and an insurance for the future. It affords some people comfort to know that if they have a serious medical issue or if their health deteriorates, they will be able to avail of necessary medical care and medication, irrespective of their circumstances.

It must also be stressed that the medical card is a requirement for any elderly person who requires aids and appliances from the HSE. This policy change will result in the costs of the aids and appliances being foisted onto the older person. The medical card is a prerequisite to being given a walking stick, walking frame, wheelchair or even a hearing aid. It will be little consolation to the thousands of elderly people who require these aids in their daily lives to be to be stripped of their medical card and awarded a GP visit card instead. These aids can be very costly and this move may result in people being unable to pay for the aids they so desperately need. Pensioners have not been immune to the recession and have seen their incomes fall drastically. In this budget alone pensioners have been hit with drastically increased prescription charges and are feeling an additional pinch on top of paying for their medication.

Older people have a fixed income and the cumulative and multiplier effect of cuts and rising costs is now taking an unbearable toll. Although the State pension has been retained, people are experiencing multiple pressures as a result of creeping costs for necessary goods and services, reduced entitlements and benefits, and the introduction of new charges and taxes. Elderly people are reporting less money in their pocket year on year, and many state they live on the brink of poverty. Fuel poverty is increasingly evident, as is isolation in the home. There is no exemption for pensioners from the myriad of charges, taxes and increases imposed by this Government, yet the comfort of the medical card is to be robbed from 10% of those who are over 70. It is unconscionable that this Government would strip elderly people of their vital medical cards. These people worked diligently and are being targeted in their later, and what should be their golden, years. This political decision is a disgraceful act which must be deplored and condemned. Our pensioners and elderly should be entitled to a reasonable standard of living and protection from these savage cuts. Instead, older people are being hit with a raft of painful cuts. We must stand up for the elderly in our community who have earned the right to be treated with dignity and respect.

Dishonesty is destroying the reputation of politicians and of the political system. There is deep and understandable cynicism in the population generally about politicians and politics. It is being driven by dishonest legislation like the Bill we are discussing which deals with income limits for medical cards for the over 70s.

It is important to note what the current Government said in opposition about the issue of medical cards for the over 70s. The Minister for Health, Deputy James Reilly said of the Fianna Fáil-Green Party Government:

The Government has lost touch with the people and misled its own backbenchers. It thought it could carry out this attack on the elderly under the guise of patriotism, when it was more like an act of terrorism.

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?

Those are the words of the Minister who has twice changed the income limits for over 70s. The Taoiseach, Deputy Enda Kenny, said:

Elderly people do not want to be pressurised about means tests and application forms or have to worry about their property, their savings, what they have in the bank, whether a man from government will call to their home or if they will lose their right to the medical card ... they know, understand and appreciate the value of that little card, which is a psychological comfort to them. They know it brings medical benefits when they need them. It is the one certainty of which they are sure in their twilight years.

What did they say when they spoke from the back of a lorry at the protest by elderly people in 2008? According to Miriam Lord in The Irish Times, the current Taoiseach said, "To take away your right to have a medical card beyond the age of 70 years - I reject it! The cheek of them. Shame on them. Shame. On. Them." The current Tánaiste, Deputy Eamon Gilmore, went on to say "how dare the Fianna Fáil Government disrespect our elderly ... These people 'who worked hard all their lives, often paid high taxes and only want the peace of mind of having the medical card if feeling unwell.' "

He went on to say, "While some tinkering around with income limits may be sufficient to satisfy some of the more gullible Government backbenchers, it won't satisfy the public who simply want to see this plan scrapped". The Minister, Deputy Reilly, the Tánaiste, Deputy Gilmore, and their parties went on to make even more extensive commitments and promises in their 2011 election campaign. They promised to ensure that the vulnerable would be protected. This legislation shows the dishonesty of their position and the fact that while the Government is allowing very wealthy people in our society to get off scot free, it is targeting elderly and ill people and people on low incomes.

This year's budget targeted the elderly again. A total of 40,000 medical cards were targeted for withdrawal in that category. Some 170,000 medical cards have been targeted for withdrawal overall resulting, we are told, in a saving of €149 million. This includes the targeting of the withdrawal of 35,000 medical cards among over 70s with a saving of €25 million. There is to be savings from 22,000 medical cards for those returning to work and their cards are going to be withdrawn targeting a saving of €11 million. A total of €113 million is to be saved from what is called "probity". This simply means withdrawing medical cards from the general medical card population.

We have been told in the Chamber time and again by the Minister for Health, the Minister of State, Deputy White, and others that there is no policy change in respect of discretionary medical cards. No one should believe it. Every Deputy in the House and every Senator in the building knows that there has been a policy change and that elderly people are being targeted by the Government for the withdrawal of medical cards. This is taking place every hour of every day in every constituency office throughout the country. People know the Government has changed the policy and that it is withdrawing medical cards from elderly people on a daily basis. Approximately 1,100 discretionary medical cards have been withdrawn each month since the beginning of the year. Elderly people are entitled to some peace of mind in their old age but they are now being targeted by a Government which promised to support and protect them in the 2011 general election.

Another group of medical card holders is also being targeted, that is, those aged between 65 and 70 years. They are being targeted simply because they may have a small occupational pension. These people worked in the local authority, the health board, on the roads for the local authority, in the post office or somewhere in the public service and may be in receipt of a small occupational pension or their widows may receive a small widow's occupational pension. This immediately puts them over the out-of-date income limits. These people, who have had medical cards for years, are currently losing their cards because they are a little over the limit as a result of their small occupational pension.

Earlier this year the Government changed the rules in respect of eligibility for medical cards. Two of these changes in particular are absolutely obnoxious and should be reversed. I am referring to the withdrawal of the travel to work element. Now, an applicant must bear the first €50 per week of travel to work costs. That may well be fine for the constituents of the Minister of State, Deputy White, in Dublin South but it is not fine for my constituents in Clonmel, Ballyporeen, Tipperary town or Carrick-on-Suir who have no public transport to get to work and who pay €50 per week and more to travel to work. This withdrawal should be reversed immediately. It is hitting rural Ireland particularly as well as people who do not live in areas where there is public transport.

There is another problem with home improvement loans. Some people who improved their homes may have built an extension for a relative. They may have upgraded the kitchen and they would have been allowed to offset the repayments on that against their medical card limit. Again, that has been withdrawn but it should be reversed and replaced.

I call on the Minister to confirm the current position in respect of expenses for childminders because there seems to be a difficulty in this regard as well. In particular, I call on the Minister to confirm whether the central applications office is seeking documentation which is less than three months old. While one may take the view that this is acceptable, let us remember that in the case of United Kingdom pensions, a person only gets one notification per year. There is a particular difficulty in getting such documentation. There is also the question of the delays in medical reviews. I call on the Minister to consider all these issues. This is particularly dishonest legislation. It is driving cynicism and destroying the reputation of politics and politicians in the country.

The alteration to the criteria for medical card eligibility is one of several restrictions to eligibility for the over 70s since the beginning of the economic crisis. The over 70s used to be automatically entitled to a medical card before 2008 but since then entitlement has been increasingly restricted. The Government is planning to save €113 million through medical card probity and has set a target of €666 million in savings next year. The Government has justified its restriction of medical cards by pointing to the increased numbers of people now availing of the cards. The rate is now at the highest level ever, with over 44% of the population currently holding medical cards. However, health analysts, including as Sara Burke and the Irish Patients Association, have pointed out that this increase is down to more people needing medical cards. The IPA has stated, "This situation is more of a reflection of the current economic environment; falling incomes and other calls on disposable income" rather than an increase in the number of people on the live register.

While the Government's commitment to universal health care has been widely welcomed most commentators, including doctors, believe the current approach of introducing free general practitioner care for those under five years while restricting medical cards to others who might have a greater need for medical care is a contradictory and confused approach to the issue and flies in the face of the programme for Government's commitment to developing a universal, single-tier health service which guarantees access to medical care based on need, not income. In response to measures announced in budget 2014, the chairman of the Irish Medical Organisation's GP committee, Dr. Ray Walley, said that the Government "is presiding over the widespread rationing of discretionary medical cards for people with long term illnesses and real medical needs and now it's engaging in a stunt by extending these cards to tens of thousands of children in relatively wealthy families who by any measure do not need them."

Age Action Ireland has also said that it is concerned at changes to income limits for the over-70s medical card which this year will see the loss of another 35,000 cards and stated: "It is contradictory to be removing means-tested cards from a section of society which has high medical needs, in a budget which is rolling out free GP care for children and heralding it as the roll out of its universal primary care plans".

The Government’s approach to health is fundamentally confused and contradictory. It is not based on need but is driven primarily by financial concerns. Worryingly, part of this can be attributed to demands made by the troika. Although initially the troika seemed quite silent on health, it increasingly became vocal on conditions in health and stated the Government must "tackle the unsustainable growth in medical cards". The approach then is one based on fiscal concerns, particularly in the context of the EU-IMF programme, and not on the Government’s professed primary objective of need.

While there are fiscal constraints on the State in funding the health sector, an inconsistent and incoherent approach to health risks is undermining the health and lives of people. Where is the impact assessment of measures introduced in budget 2014? How were certain people’s health needs prioritised over others? It is obvious that such needs were not taken into consideration and that policy is being driven by budgetary concerns and the slashing of numbers, rather than on health care concerns. One could be forgiven for thinking that the Department of Public Expenditure and Reform is now running the Department of Health.

The huge risk being run at present is that there will be a permanent impairment to the health sector in Ireland and therefore to the well-being of citizens. In their TASC report, Eliminating Health Inequalities - A Matter of Life and Death, Sara Burke and Sinéad Pentony noted the dire consequences of slashing spending on health in 1980s:

... which were made in response to the then weakness in the public finances. It took a considerable time for health spending to recover from the cuts in the 1980s, and it can be argued that the provision of health services did not fully recover from those cuts.

In other words, the reason the health service is marked by the obvious problems with which all Members are familiar is precisely because the Government previously slashed funding on health and the service was never able to recover. It would be utter folly for the current Administration to repeat that same mistake, rather than learning from the past.

The Government’s commitment to universal health care is to be welcomed as it presents an opportunity to redress inequalities in Irish health care. Burke and Pentony noted:

... despite an overall improvement in the health of the Irish population [over the decades], very little has been done to address inequalities in health between high-income and low-income groups. [This means] if you work at an unskilled job and live in a deprived area, you are more likely to die earlier than a professional worker living in an affluent area.

Inequality in health is most starkly and sadly illustrated by the figures for Traveller people. Traveller men and women have four and three times, respectively, the mortality rate of the general population. Suicide rates among Traveller people are six times higher and account for approximately 11% of all Traveller deaths, while the infant mortality rate for Travellers is 3.5 times higher. These figures are frightening in a country that claims it cares. The Government must now act to redress such inequalities by introducing swiftly a system of universal health care that is equitable and that is truly based on need and not on income. Sadly, the Government’s strategy for so doing is undermining its best efforts as it is more concerned with achieving savings targets through restricting eligibility rather than taking a patient-centred and needs-based approach.

Too little is happening too slowly. Although Members have been promised a White Paper on universal health care since 2011, outlining the details of the proposed universal health care system, where is it? I acknowledge a preliminary paper was published this year, namely, The Path to Universal Healthcare, but Members still await the actual White Paper. Although groups have been established to research and oversee the implementation of a system of universal health care, there seems to be very little action from the Government and what it is doing is undermining directly its own professed goals. How much longer must Ireland be one of the few countries in Europe without universal health care? How much longer will Members accept that people are dying prematurely and are suffering disease and injury simply because the Government is incapable of tackling Ireland's two-tier system, in which those who can afford health care pay and those who cannot suffer the consequences?

I wish to share time with Deputy Terence Flanagan.

Aside from the legislation itself, one point has struck me as being extraordinary in the Chamber today. I am surprised by it because while this legislation on the surface appears to be draconian in many respects, certain aspects of the medical card regime have improved over recent years. I refer to the lack of Government speakers on the issue. While Members on this side are always arguing that they cannot get time, there appears to be no difficulty in so doing today. I am sure the Minister of State, Deputy White, must be a little perplexed that he cannot get his colleagues to come into the Chamber to speak in favour of the legislation. I am unsure whether any Government Member has spoken in favour of it. Nevertheless, I certainly am happy to go along with certain aspects of the legislation.

In the first instance, however, I note this legislation is on foot of the budgetary measure changing the eligibility for medical cards for people over the age of 70. Following the budget, a view has formed among elderly people, who Members should recall are those who worked during an era in which they were obliged to pay more than 60% in tax and when mortgage rates were between 10% to 20%. The rates hovered around 20% for many years in the late 1970s and early 1980s. There is a certain sense that such people were perceived to be easy pickings in respect of the prescription charges, the telephone allowance or the medical card. I do not necessarily agree with this and do not believe that was the Government's intention but it certainly was the message that came across. Again, it shows the weakness in Ireland's budgetary system because it would be to the Government's advantage to come into this Chamber in the months ahead of a budget to outline the amount of funding it has available to it and its proposed allocation thereof and then to ask Members whether they could come up with a better proposal. In this context, it is easy to lament the cutbacks and is easy to lament the reduction in services or the increase in taxes. However, Ireland still is spending beyond its means and this must be addressed further. The economy will not get back into shape until the finances are back in order. This is the reason I am surprised that Government Members have not come into the Chamber to speak.

I have a number of points to make and while I am not a spokesperson for the Government, it is important to point out that notwithstanding the increase in the number of people on the live register, the numbers of medical cards issued have risen dramatically. In 2004, there were 1.14 million cards while in August 2013, there were 1.863 million cards. Notwithstanding the increase in the numbers on the live register, this constitutes a dramatic increase. Moreover, the number of medical cards in circulation has increased by 62% between 2004 and August 2013. Second, the coverage of the population for health services through medical cards has increased steadily since 2004 to reach almost 41% of the population by August 2013. When GP-visit cards are included, that figure increases to 43%. I reiterate the caveat about the economy but these basically are good news stories and I am surprised that Government Members are not in the Chamber to push them.

On the other side, in my dealings with the HSE, in general I have found its staff to be fine. Mistakes of course will be made and Members are familiar with the high-profile cases that end up on the chat shows or whatever and which are not possible to defend. Errors will happen and this is where I believe the HSE and the health services have faltered. I will cite a statistic that does not show the health service in a good light. In 2009, approximately one in 18 medical cards issued were discretionary while in 2012, the comparable ratio was 1:33. I believe medical cards should be issued for medical reasons and not as financial assistance cards. This is the reason it is really important to have consultations. The system has changed in that it is now managed centrally and, consequently, what is now missing is input from the community welfare officer, the public health nurse, the local politician, the local health board member or whoever. Previously, such people had an input into the granting of medical cards but this practice has now ceased. As society becomes more technologically advanced, lots of shortcomings emerge and in this case, the interface with people is one such shortcoming. I would be happy to support the broad principle of this legislation, were a commitment given about the discretionary card for those who are actually in need. The Government has a policy in which money follows the patient, whatever that might mean, as I am not quite sure. However, a policy in which money follows the patient and need would make a lot more sense. It is the same in respect of providing the medical card for everyone aged from zero to five.

There are many children aged six, seven and eight in dire need of a medical card whose the family's earnings are over the income threshold for eligibility but, due to the special needs of the child, they are in difficulty. They will get a medical card for the child on most occasions, but not always. It would be preferable if that cohort of people were to get a medical card than to have universal provision. I do not believe in the principle of universality because it does not address the need.

There is an anomaly in the legislation with regard to the income threshold applying to a married couple. The income threshold has been reduced to €500 per week for an individual and €900 per week for a couple. I tabled a parliamentary question on this issue, the reply to which stated that it is easier for a couple to cope with the cost of living and, to bring it down to simplistic terms, only one light bulb is needed for two people. The same argument can be applied to a sister and brother or two individuals over the age of 70 who share a house. The income threshold qualification for those individuals is €500 per week and this is the first time in legislation on this area that there is discrimination against married couples. Unfortunately, I am not a member of a committee but I will certainly consider tabling an amendment on Report Stage to restore equalisation in the legislation. This anomaly sends out a message of discrimination against married couples.

Approximately 2 million people have a medical or GP visit card and 43% of the population are in the medical card system. I would like to know what percentage of that 43% have private health insurance. In theory, there should not be any of those in that system and, if there are, it is a clear indication that there is a lack of confidence in the health service. The chief executive officers of four hospitals wrote to us recently expressing concern about the services being provided. I represent a constituency in which there is no general hospital. It is probably unique in that respect. It has not had a general hospital since the foundation of the State and prior to that. Perhaps Leitrim is the only other county in a similar boat. I am not sure if there was a general hospital in Carrick-on-Shannon but Wicklow does not have one. I have encountered a few cases involving people who have passed on where I would be almost certain - whether it was due to lack of resources or other reasons - that should not have been the case. I definitely believe there was misadventure or neglect at the heart of it, for whatever reason I do not know but it is to be hoped that, in time, it will be established.

I want to deal with the issue of the prescription charge. I was an advocate of it from the perspective that it was a quantity control measure. One would find on visiting houses that there would be lockers filled with unused medicines. The charge was to be a quantity control measure, not a revenue collecting measure. Unfortunately, the Government has developed it as a revenue collecting measure. There is a maximum charge of €25 per month, but that is a good deal of money for an elderly person. I ask the Government to reconsider the impact of that charge on elderly people in particular. The charge is €2.50 per prescription item.

I am a believer in the concept that no one should get something for nothing, notwithstanding that there are people in difficulties. I believe most elderly people would support an idea with regard to the medical card. In the case of the free travel pass, I have met several active retirement groups who expressed the view that they would not mind paying a €1 or €2 per journey, once it was not used as a revenue collecting measure. It could be a quantity control measure or a means of monitoring the position. I would not be adverse to a charge of €1 per visit for a medical card holder provided that next year the charge would not be €5 and €10 the year after that. I do not believe people by and large would have a difficulty with a small charge. While some sections of the media might hammer the Government initially for bringing in such a charge, it could explain the advantages of it and that it would put a certain status on the card. People are very fair and reasonable.

I want make a few basic points. With regard to the discretionary medical card, it is important that the interface with and knowledge of the local person is taken into consideration. It is fine then to reduce the other sections provided the discretionary card follows the need.

We have a community first responder scheme in Wicklow. I have often raised this issue with the Minister, Deputy Reilly. The issues of concern to people who are isolated medically are meningitis in the case of a young child and cardiac arrest. The community first responders in Wicklow have 400 or 500 people trained in a voluntary capacity. When an ambulance is called out, a mobile telephone number is concurrently dialled and the local person who has been trained - there are volunteers on duty in almost 30 locations - makes their way with a defibrillator and the oxygen to the individual concerned. They get good assistance from the ambulance service. When a former Minister, Mary Harney, was in office, she launched a report on it around 2006. The scheme has not been extended nationally. It is a fantastic scheme that no one knows about other than the people who avail of it. I heard a presentation on it when the Minister, Deputy Reilly, was in opposition and I would like him to read it because, for very limited resources, it provides a fantastic facility.

I thank the Ceann Comhairle for this opportunity to contribute to this debate. I share the concerns expressed that the new criteria announced in budget 2014 can be seen as discriminating against older married couples, as Deputy Timmins stated. Until now the medical card income limit for a married couple was always twice that of a single applicant. Under the new terms, the limit for a married couple is less than double that for a single person, namely, €500 for a single person and €900 for a married couple. This marks a huge decrease in the income limit for a married couple of €500 per week, when one compares the figure with the income limit of €1,400 per week at the beginning of 2013 versus the new limit of €900 on a gross weekly income limit. The Minister advised me, as he did other Deputies, that the reason for this is that "the Government recognises that the living costs of an individual living alone are more than half the living costs of a couple living together and that expenditure does not necessarily diminish relative to the number of people in the household". I have concerns about that statement in that when one half of a married couple dies, there is no reduction in the outgoings of that household except for a reduction in basic food costs. The surviving husband or wife still has the same fixed household costs such as electricity, the property tax, television licence, home insurance and so forth. I ask that the Minister would set out the data that were used by the Department in reaching this conclusion and if those data have just become available or if they were available in the past, the reason they were not taken into consideration in the past.

I welcome the moves in this Bill to improve medical card probity measures to ensure those who are no longer entitled to a medical card or a have a medical card in error and their situation has improved will no longer receive one at a cost to the State. I do not believe that anybody wants to see wastage, particularly in terms of people getting a medical card who do have a desire or a need for one. The Minister has provided reassurance that those entitled to medical care and who have a genuine case and need because of financial hardship will get a medical card. Those who no longer are eligible for a medical card as a result of changes will be entitled to a GP-visit card, and that provides peace of mind for senior citizens. Many people have been scared, uncertain and worried as a result of media reports about the new measures. I hope the reassurances provided by the Minister to address people's fears are solid. The worst concern is fear itself, especially for older people, and we must be careful of that.

Another commitment given by the Minister is the roll-out of free GP care for all citizens, and that remains a priority for Government. We know that the cost of attending a GP and paying for a prescription is much higher in this country relative to other countries, particularly for families whose members are sick and need to visit a doctor. Some such families are no longer attending a doctor as a consequence.

The commitment of the Government to the roll-out of free GP care will help those hard-working families to be in a position to attend a GP when in need. Approximately one half of the population will have access to free GP care by the end of next year. It is important that the Government continues with its reform plans to ensure that a fairer health system is accessible to all. I welcome the introduction of the free GP card for children aged under five years which will go some way to lessening the financial burden of hard-pressed middle and lower income families. A total of 240,000 children are expected to benefit as a result of this new measure. However, I am concerned about the discretionary medical cards. There is a fear that the Department of Health is clamping down and people with terminal illnesses may not be entitled to a medical card. Other Deputies have voiced this concern. It is hoped that genuine cases will be dealt with in a humane manner and that the medical card will not be taken away.

I am concerned about the aspect of data-sharing between the Department of Social Protection, the PCRS and the Revenue. Are there any plans to enable data-sharing between the PCRS, the Department and Revenue to speed up the application process, to improve efficiency and to avoid complications, considering the large volume of applications for medical cards in recent years? I ask the Minister of State to comment on the current relationship between the PCRS, the Revenue and the Department. Are service-level agreements in place?

I understand that the HSE has endeavoured to undertake a communications campaign to inform people of the changes in eligibility. Any moves to improve communication with clients is welcome. I note that the PCRS plans to be aware of the use of language in its letters being sent to clients. This is very important in light of what happened with the Revenue and its methods for communicating about the local property tax. Lessons must be learned to ensure that the wording of letters is more clear and considerate of people's situations. I have a concern about the poor communication from the HSE about the long-term illness scheme. Twelve illnesses are covered under the scheme, including MS, for example. Many of those who apply for medical cards are already covered under the scheme and this needs to be publicised better by the medical profession and by the HSE, so as to cut down on duplication of medical card applications and so that time and money is not wasted in processing unnecessary applications. The same point can be made about the drugs payment scheme. I ask the Minister of State to comment.

I will take this opportunity to highlight my concerns about the accident and emergency department of Beaumont Hospital in my constituency. The national target for accident and emergency department waiting times is that 95% of patients must be treated within a six-hour period once they present to the department. The national target is for 100% of patients presenting at accident and emergency departments to be treated within nine hours. However, Beaumont Hospital currently treats only approximately 70% of all new unscheduled patients within nine hours, thus falling below the national target by 30%. Could the special delivery unit focus its attention on accident and emergency departments in general and on Beaumont Hospital in particular, before the winter season begins?

I have been advised by the HSE that the number of patients waiting on trolleys in the Beaumont Hospital accident and emergency department is a systemic problem and is regularly in excess of 100% capacity. This is as a result of the delayed discharges from hospital wards. Could the Minister of State investigate this situation? There has been an increase in prescription charges over the years. I hope this is not a revenue-generating policy from the Department, although it possibly is such. The limit of €25 could be looked at because it is a lot of money for elderly people.

There is no doubt that this Bill will be passed, given the Government's majority. What should be noted about this debate is the complete lack of speakers on the Government side of the House over the course of the debate. They will press the buttons and support the Bill but there has been a paucity of speakers and most of the contributions have been from this side of the House.

This is the second occasion this year that the House has considered legislation to do with eligibility for medical cards. The Taoiseach and the Tánaiste revved up the crowds in 2008 but this is contrasted with the manner in which they now deal with medical card eligibility.

I ask the Minister of State to consider some aspects of the Bill in advance of Report Stage. Like other speakers I am concerned at the manner in which the figure has been arrived at. Couples living together are being discriminated against because their weekly income threshold is being reduced by €100. This is a significant departure from previous Bills amending eligibility for medical cards which gave couples double the allowance of individuals. I agree with Deputy Terence Flanagan that if the Department is using a new formula for assessing eligibility this should be explained to people. Will this formula be used for all eligibility applications? It marks a significant departure from current practice.

This is the second time that the Government has reduced the eligibility for a medical card for the over 70s. Will there be subsequent reductions? The Government is also making health insurance more unaffordable, in particular for this cohort of people. The Taoiseach spoke this morning at Leaders' Questions about older people needing more expensive policies. I agree that is the case but these are the people whom the Minister for Finance, Deputy Noonan, on budget day described as having expensive gold-plated policies. He announced the cut in the tax credit by stating that it would only affect those with gold-plated policies. However, for most older people, their policies are more expensive and they use them, but they are not gold-plated by any means. These policies provide the security of being able to obtain a bed in a ward or having timely access to services. There is nothing gold-plated about that but because of their age or condition, some people will have to pay more.

I am aware of a constituent who suffers from chronic pain syndrome at the age of 39. I spoke to her on budget night and I have referred to her case previously in the House. She has a requirement to travel from Mayo to the national pain centre at St. Vincent's hospital every six weeks to have her condition treated. Her VHI policy - which she still pays - will rocket in price because of this taxation decision. She does not have a gold-plated policy; it is a policy directly relevant to her condition. The issue of discretionary medical cards is broader than this legislation. My constituent will now be forced to defend her right to have a discretionary card because it is specific to her condition and it was given on discretion.

Even the use of the term "discretionary" is wrong. I agree with Deputy Terence Flanagan that communications about the long-term illness scheme are appalling. People do not understand it. I would not like to compare the medical card staff in the office in Finglas with the Revenue Commissioners.

They are doing a hell of a good job currently and they are trying to deal with people. While I disagree with the reviews, the forms are clear and the staff in Finglas are trying their level best. There were hiccups in the beginning, but they have got everything together and they are good to deal with, in my experience. The reality is that discretionary cards are being withdrawn from people who have cancer or children who have disabilities who require them to be in care. The notion of giving free GP care to under-fives while not being in position to give a guarantee to a child if he or she has a serious illness that the or she will have a medical card when he or she is six is wrong. We all aspire to free GP care for under-fives, but when children with serious or terminal illnesses cannot get that guarantee, we need to examine our priorities.

The Taoiseach referred to cancer patients and said this diagnosis no longer strikes the fear into people that it used to. He is correct but he is able to say that while looking on from a distance. When people are given that diagnosis, no matter how good the prognosis is, it strikes fear into them and their families in the days and weeks afterwards. People will have to battle and go through the process of applying for a card and that will not assist them to deal with the fear. The health services need to liaise with the Irish Cancer Society and cancer specialists regarding a fast-track system for people with serious illnesses. Motor neurone disease is another example. It is incredible that given the prognosis for sufferers and the care they need, there is no system to fast-track applications for specific conditions. That needs to be implemented.

On budget day, the Taoiseach stated that only 3% of those aged over 70 would be affected by this change. He again gave the impression, as the Government tends to do in its communications, that people should not worry because only rich, gold-plated individuals will be hit by this and everybody else will be fine. To achieve the savings target, however, 35,000 medical cards will have to be withdrawn and, therefore, either the Taoiseach is wrong or the savings target is wrong. The amount the Bill proposes to save needs to be clarified.

Probity measures are also an issue. The notion of probity suggests something is wrong with people who have a card and that they should not have it. They comprise a small cohort and some were given discretionary cards because of local knowledge and input.

It is frustrating that medical decisions are taken on the basis of a form without engaging with the applicant. Either the Minister of State or the Minister for Social Protection committed to increasing the number of doctors assessing medical card applications but it is one thing to read a form and look at a range of conditions. It is another to sit down face to face with a patient and make a call. If the Government wishes to emphasise decisions made by doctors, they must meet the people on whose applications they are deciding. One cannot diagnose a person's medical condition on the basis of a form.

The notion of a card being discretionary suggests people can do without one. I received an e-mail from a constituent a few minutes before I came into the Chamber. His mother has a serious medical condition and her discretionary medical card has been withdrawn. The husband has a small business and is struggling like all small business people and he is trying to keep his family going. The card was reviewed a few weeks ago and it was withdrawn. This is a serious condition and I have asked for the details, which I will pursue, but this person is going through incredible distress, as are many thousands of others who are getting these letters. The worst element of this is that people are attending doctors only to find out that their medical card, which might have an expiry date in 2014 or even 2015, has been withdrawn from the list. This is the first they have heard about there even being a question over the card or that it is subject to a review. Their doctor has been told that the person no longer has a card. Communications issues need to be addressed because this is wrong.

We are saying to older people that they are expendable. The statements and rabble rousing engaged in by the Taoiseach and the Tánaiste in 2008 on this issue stands in stark contrast to this legislation which will pass Second Stage later. The loudness of the silence on the Government benches has been noticeable throughout the day.

I sincerely thank the Technical Group for time to contribute to the debate. As the previous Deputy said, when one looks around the Chamber, it is a fairly lonesome sight. I very much respect the presence of the honourable Members of the Others, so-called, who were here to say their piece on this important subject. I respect their integrity and the honourable position they have taken. They were elected under the flag of a political party but they would not be bound by that or held back in their conviction and in what they believed in their hearts to be right and wrong. I appreciate and respect their views and how forthright they were in making the sacrifice they had to make to stand up and say what they believed was right or wrong. Where are the other Others? Where are the people who went before the electorate and said Fianna Fáil had run the country into the ground? They condemned and they castigated.

I was not a Member at the time but I was not in another world. I recall what the Taoiseach said when he was leader of the Opposition and what the Minister for Health said when he attacked his predecessor. He said she was hiding behind the HSE every day and night. When Opposition Members question him now, he hides behind the HSE. God knows he is substantial enough that he should be able to stand up for himself, not to mind hiding behind anybody, but, unfortunately, he is responsible for presiding over a disastrous set of circumstances that have led us to this point. The one thing elderly people, whom we respect, hold dear in our beautiful, small country is their medical card. It did not fall into their laps; they earned it. They are our parents and grandparents who worked hard.

The Government parties had the cheek to say this change would save more than €100 million but it would not hurt or affect anybody. They said they would make these massive savings but they would not cut anything when we all knew a secret decision had been taken earlier this year by them to cut more than 40,000 medical cards. This will have a catastrophic effect on people who are vulnerable because they are living on low incomes and need every penny they have.

I have to look to my colleagues in County Kerry whom I competed against to get into the House. Where are they now? They went before the people of County Kerry and made serious promises. Where are they tonight? They will run into the House later when the division bells ring and they will vote to hurt the very people who voted for them. Fine Gael and the Labour Party secured a substantial vote, and later they will hit the very people who voted for them. If they think the electorate will forget this, they will have another think coming. The electorate will wait and bide its time and the people will have their say, in the same way as the yes men who will run into the House shortly to vote to hurt and affect these respectable people.

Those respectable people will remember what was done to them. When Fine Gael and the Labour Party rang the buzzers on the doors a couple of years ago, the welcome they got was very warm. They said they would have to get rid of Fianna Fáil and they promised they would do everything better. The people will remember what better is. Better is hurting our elderly people and taking away their medical cards.

I received a heartbreaking telephone call before I came into the Chamber from the mother of a five and a half year old boy. Yesterday morning when she gave him a cuddle, she hurt him when she put her arms around him because he is waiting for a procedure to be carried out in the children's hospital in Crumlin. Unfortunately, the nuclear X-ray machine will be out of use during January and it is in limited use at the moment. I was so upset after the telephone call that I telephoned Great Ormond Street Hospital in London to see how much it would cost for the X-ray and the procedure required to be done privately there. The parents do not have the money to pay for it but I would undertake to fund-raise for this operation.

Is it not some indictment of where we are today in terms of health care when a five and a half year old child is in pain and is sore? I cannot get it out of my head. The only alternative I can see to help this child in the immediate future is to have the X-ray and the procedure done privately in England. This is very upsetting. If it is upsetting for me, can one imagine how upsetting it is for the parents of that child who is sore and in need of a procedure which cannot be done because of cutbacks?

For the Minister to continuously hide behind the HSE is upsetting because the Government promised so much. Its members did not need to make the massive promises they made to get into power. If the members of the Government had half a brain in their heads, which I am sure they have somewhere, they would have known they would get elected. They did not need to make all these promises but they did regardless. It was like the Taoiseach saying in an after dinner speech that he wanted to do away the Seanad in case it would get a couple of more votes for him, although knowing in his heart and soul he did not need to do that. He got a fair kick for that. It is the first of many kicks he will get and it will go on for a long time. I do not know how to express my opinion of the Government given what it is doing, but it will be remembered forever.

The cut to the telephone allowance will cost the State money. People's pendants are connected to the telephone. If somebody who has done away with the landline falls in his or her house, he or she will not have that backup service. A person might have a small incident in his or her house but by not being able to contact somebody, the situation could be fatal or the person could finish up in hospital for a prolonged period, perhaps with a broken hip or some other such misfortune. If that happens, it will cost the State a lot more money, so it will not save money by doing away with the telephone allowance.

I refer to the ambulance service and centralising the emergency call centre in Townsend Street in Dublin. That facility is not fit for purpose because it is a fire station to which minor changes were made. All of a sudden somebody decided it would be a great idea to centralise our emergency call centre. Since that happened, lives have been lost because under the previous system, people knew localities. We had a situation in County Kerry where an ambulance was called to an address in Tralee but it ended up at the same address in Cork, 60 miles away. These are the types of stupid decisions over which the Government is presiding, things which are not saving money but are leading to situations where people do not have the same delivery of service or the same confidence in the service. For anybody telephoning 999 now, it is a chance in a million that one might be seen afterwards. One might say that is an exaggeration but I could go through the mishaps, cock-ups and mistakes which have been made since the call-out centre was centralised in Dublin.

We can see what happened with our community welfare officers and centralising the processing of medical cards. I very much appreciate the work being done by the people in the centralised centre for medical cards. Those people are doing their best because this was thrown at them and it is not their fault. The Government has created a disconnect between the people looking for a medical card, the community welfare officer who might have been dealing with the people, and the people in the locality processing the applications who had local knowledge and could telephone the community welfare officer to ask about the situation in a particular household. That has all been done away with. The Government has created a complete disconnect between the person looking for a medical card and the people adjudicating on whether the person should get a card.

Another awful dirty trick which I would like to highlight concerns medical evidence. I mentioned this in the audiovisual room a number of months ago when people from the Department gave a presentation. Again, I do not blame the people in the Department who are dealing with the deck of cards the Government gives them. When applying for a medical card, disability allowance, illness benefit or any such scheme, one is asked to give medical evidence from one's doctor, which is clearly stated on many documents. Every public representative knows that if one gives medical evidence from a doctor, one will be refused. The reply one will get is that, based on the medical evidence submitted, one is being refused because the HSE does not believe the medical evidence is good enough. What it is saying is that one should have a report from a consultant, but it does not tell one that because the Government wants applications for medical cards, disability allowance and illness benefit to be refused. This is a magic formula when it comes to issuing refusals because it catches an awful lot of people out.

A person who may be elderly or ill might not be under the care of a consultant but will get a letter from the doctor which he or she will think is the best he or she can give. If that person is refused on the basis of the medical evidence, he or she will ask what other evidence he or she can get. If he or she is not under the care of a consultant, he or she will not go to one because it will entail spending €150 or €250. A person applying for one of those schemes is looking for money and not to spend it because he or she does not have it to spend.

When the presentation was being given in the audiovisual room, I asked the following simple question. Why is it that the HSE does not tell people? Why does the Minister of State, Deputy White, not direct the people who are dealing with these schemes to state clearly that the HSE does not accept doctors' reports when it comes to applying for medical cards, disability allowance or any of those schemes? Just in case I was wrong, I asked many of my colleagues if they were having the same experiences, and they were. Besides being appointed a Minister of State, Deputy White was elected to the House, which means he has an electorate behind him and people are coming to him with their problems. The funny thing is that he knows everything I am saying is the truth and that I am right.

He knows that the HSE will not accept the evidence of doctors any more. It is an absolute no-no the minute it is seen. The doctor's report might say the applicant in question is under the care of a certain consultant, but that will not be enough. The report has to come from the consultant.

I can prove that what I am saying is correct. I deal with an awful lot of people whose applications have been refused. I tell every one of them to go away and get the evidence from a consultant. When they get it, we send it in not as an appeal but as a request for a review. We are successful in the majority of those instances. The proof of the pudding is in the eating. When I follow what I am told is the correct procedure, it works. That is the proof. I am just one of 166 representatives in this House. I am sure everybody else has the same experience, regardless of whether the Minister of State wants to admit it. Maybe he cannot do so in his position as Minister of State. He might feel his job is to say I am wrong even though he knows I am right. He is shaking his head. I will be delighted to hear what he will say.

I would not misrepresent something. I will tell the truth in my reply.

I believe that 100% because I know the Minister of State is an honourable man. I appreciate that he is a respectable man. All I am saying is that he might not be able to be as forthright, now that he is a Minister of State, as he would be if he were not a Minister of State. I would not dare to question his integrity as a politician. I would not do so in a million years.

I will come back to why we are having this debate in an empty Chamber. The Chamber is empty because the people who will vote with the Government know they are wrong. They know they are betraying the electorate. They know they have been dishonest with the people they asked to vote for them. I really believe that tonight, above all nights, is a special night in this House. The Labour Party and Fine Gael are hiding. The people who made all these promises are hiding. They condemned Fianna Fáil, Sinn Féin and the Independents. They said they would do it right if they were given a chance. My God, they are making a fair mess of it. They were given a golden chance. They needed to be honest, but they were not.

I would like to make a point that I have made previously in this Chamber. I have seen a Sunday newspaper referring to the Minister for Social Protection as "Wonder Woman". I know what Wonder Woman has presided over. I know where the leaks from the Cabinet table are coming from because there is no such thing as a free supper. There is no such thing as free publicity for those who are given titles like "Wonder Woman". This Government will be remembered for a long time. I hope it will also be remembered that a Sunday newspaper decided, in the same week as a budget attacking vulnerable people was announced, that it was a good idea to christen the Minister for Social Protection with the title of "Wonder Woman". It will be remembered for a long time. Somebody will remember it. If people forget it, I will remind them if I am still here. If I am not here, I will remind them from wherever I will be.

I wish to speak about the junior doctors issue. It amazes me that people can be so selective about the European directives they adopt and those they do not. Mysteriously, our Government is able to ignore the European working time directive, which dictates the number of hours people can work. It does not act in the same way regarding other issues, such as those relating to farming and other aspects of life in Ireland. If Europe tells us to jump two feet, our Government will decide to jump five feet. Why is the Government selective in its adoption of European policy? It is crazy.

The Deputy has 50 seconds remaining.

Time goes very fast.

When one is having fun.

Yes. The Government is suffering from selective amnesia. It remembers to do certain things and forgets to do other things. It is frightening to think that people are expected to adhere to safe work practices over extraordinarily long lengths of time. It is wrong to call the people in question "junior doctors" because, as Deputies are aware, it is not as if they are all young new doctors. The manner in which they are treated is unbelievable.

The vote that will follow this debate will be remembered for a long time. The Chamber is quiet now as I look around. I cannot wait for the bell to ring. We will see Deputies running in and falling down the steps in their haste to press the button and hurt our elderly people. I hope the people, including elderly people, will remember Fine Gael and the Labour Party for a long time. There are alternatives.

I thank the Technical Group again for allowing me to use some of its time. I thank the Minister of State for being present. I thank the Acting Chairman for his forbearance.

The Minister of State, Deputy White, has the right to reply.

The Minister of State is entitled to speak for a period of time not less than 15 minutes and not exceeding 30 minutes.

The Minister of State can yield some of his time if he wishes.

Okay. I wish to address the broad issue of the Government's policy on the development of a universal GP service. I would also like to respond to the suggestion that has been made during this debate that the legislative measure we are discussing is somehow contrary to the Government's policy on the universal GP service. As I have said previously in this Chamber, I do not accept that the provisions of this Bill, however they may be criticised, are contrary to the Government's policy on the universal GP service. I am not saying they cannot be criticised. The Government is protecting access to GP services for the over 70s. It is expanding access to GP services for young children. By the end of next year, almost half the national population will have access to a GP, as the first point of contact with the health system, without the financial barrier of fees in their way.

The Government is committed to introducing on a phased basis a universal GP service without fees within its term of office, as set out in the programme for Government and the future health strategy framework. The introduction of a universal GP service that will be free at the point of use constitutes a fundamental element in the Government's health reform programme and the ultimate introduction of universal health insurance. A universal GP service will underpin the delivery of health care close to people in their communities, at the lowest levels of complexity and at the lowest levels of cost. This is a critical step on the road to introducing universal health insurance and eliminating the two-tier health system that bedevils our health services.

As the Minister for Health outlined when he introduced this debate, the State's economic and budgetary situation means it has been necessary to take a number of difficult decisions to secure the savings required. Most of these savings have been designed to ensure they do not have an impact on front-line activity and protect the most vulnerable. I will come back to that point. Approximately 350,000 individuals aged 70 and over currently hold a medical card. It is estimated that the budgetary measures provided for in this Bill will move approximately 35,000 people from a medical card to a GP visit card. Deputy Calleary asked about the precise numbers involved.

The overwhelming majority of medical card holders over the age of 70 will be unaffected by this Bill. The budgetary measure we are dealing with will affect medical card holders over the age of 70 who have the highest incomes. Each and every one of the 35,000 people - 10% of the total - who will be affected by this measure will continue to have access to free GP services without quibble and without needing to go through an application process. Their medical cards will be replaced by GP-visit cards. As has been mentioned, a person over the age of 70 with a weekly income of €500 will continue to qualify for a medical card. Similarly, a couple over 70 years of age with a weekly income of €900 will continue to qualify for a medical card.

Given that the new income limits are more than twice the level of the basic State pension of €230 per week for an individual or €436 per week for a couple, it is clear the majority of over 70s medical card holders will not be affected. I am not trying to suggest that no one will be affected. Deputies have been very straight and I have listened very carefully to what everybody has said. I will not misrepresent any of the Bill's provisions. Some 35,000 people will be affected by the Bill and will lose an entitlement to a full medical card and have it replaced by a GP-visit card. I do not try to suggest in any way that is not occurring; it is occurring. It is important to understand that the new income limits are more than twice the level of the basic State pension. I believe Deputy Clare Daly said that 80% of pensioners live on the State pension alone. While I am not sure if she is right in that figure, if it is the case, it is important to point out that the State pension is approximately half the new income limits for the over 70s medical card.

Under the drug payments scheme, the HSE will meet the prescription drug costs of these older people without a medical card who face drugs costs higher than the drugs payment scheme threshold of €144 per month. This means that a single person aged over 70 years with a gross income in excess of €500 per week, or a couple with an income in excess of €900 per week, will have their expenditure on prescription drugs capped at approximately €33 per week. The people affected will still have access to the DPS threshold, meaning that they cannot be required to spend more than €33 per week on drugs. I do not underplay or make any value judgment or suggest that would never be a difficulty for anybody in the State. I simply lay the facts before the House in order that we have a sense of proportion and clarity about what is happening. By the end of 2014, in the region of 93% of the over 70s population will continue to have access to GP services without fees through either a medical card or a GP-visit card.

Some of the Deputies, including Deputies Calleary and Terence Flanagan, raised the issue of the differential between the gross income threshold for an individual, which is €500 per week, and that for a couple, which is €900 per week. Heretofore, the single threshold was half the couple threshold. The Government recognises that the living costs of an individual living alone are more than half the living costs of a couple living together and that expenditure does not necessarily diminish relative to the number of people in the household. This differential concept is not new and is evident in other areas of public policy to which I will briefly allude. Examples include the State pension, which is €230 per week for an individual and €436 per week for a couple; the provision of the living alone increase - an extra payment for people on social welfare pensions who are living alone; differential income limits between individuals and couples which apply for medical cards for persons aged under 70 years; the assessment for supplementary welfare allowance where a differential applies whereby the rate for a dependent qualified adult is not half the personal rate of the applicant; and various items under the Insolvency Service of Ireland guidelines, where a significant extra sum is not allowed per month after tax, PRSI, and so forth for a couple compared with a single person.

I will reply to some of the points made in the debate. Deputies touched on the issue of the discretionary medical card. I believe Deputy Timmins expressed the view, which is often expressed, that there should be an entitlement to a medical card for medical reasons. Other Deputies continue to assume a person can qualify for a medical card for a medical reason. I know there is a lot that divides us and this debate is a difficult one. Many Deputies said we need to remember the humanity and ensure the system is applied and administered in a humane fashion, with which I entirely agree. However, the system is the one that has been in place since the 1970 Act. That Act does not allow a medical card to be allocated on the basis of a medical condition.

Deputy Healy Rae pressed me on the issue of doctors versus consultants. The involvement of a doctor, consultant or any medical person in the assessment of entitlement to a discretionary medical card is not to give a medical report as to a person's illness or a diagnosis. That does not arise in the case of a medical card. Deputy Timmins suggested that should be the case. He may be right and I can come back to that in a minute. However, that is not the position. The involvement of the doctor is to give a view or help in the assessment of the application of a person who is over the income limits but has extra expenses associated with a particular medical condition, which could include attendance at a doctor or the need to travel, for example. The doctor's involvement is essentially to help the HSE to judge whether that is fair and whether the medical condition or illness would reasonably give rise to those kinds of expenses. However, it is still an assessment of needs. We can have a discussion on whether that is right or wrong. I reiterate to colleagues that there is no medical diagnosis involved in the decision to give a medical card, discretionary or other. It is not done on the basis of a medical condition.

Deputy Timmins developed the point and suggested it should be where there is a need, which I understand. We are all human beings and can all see that where an immediate need is presented to us, the health service should react to such a need that is current and present. I understand that. It is the humane response anybody would have. As well as being humane people, I hope, we are also legislators. We need to work out what sort of system we would need to have and what kind of law we would need to introduce if we were to give medical cards on the basis of medical conditions or illnesses. First, we would need to change radically the 1970 Act. We would need to define that a person with a medical condition diagnosed in a particular manner would be entitled to a medical card. We would need a list of medical conditions to which it would apply. The diagnostic basis would need to be set out in legislation or in regulations.

I know people's eyes glaze over when we go into this part of the discussion, which I can understand. When we looked at the issue of universal access to GP services last year, people asked why we changed course given that the programme for Government contained long-term illness. We also had the other route we had proposed taking, after which we discussed chronic illness. It would have meant we would have needed to legislate in considerable detail for the awarding of medical cards to people with particular illnesses. We would have needed regulations to govern the diagnostic basis, whether it was for asthma, diabetes or various cardiovascular conditions. We would have needed very complicated legislation to allocate medical cards on the basis of a medical condition. That is why we took a different view of how we should reach the ultimate aim of universal access to GP care.

People would need to think twice about the idea of doing it through a particular illness or condition. That is not to say I disagree with people who say the humanity of the situation must constantly be before us. We have the discretionary card precisely so that it is not just the strict case of either satisfying the means test or not, resulting in either being in or out. That is why we have taken the approach to allow an extra discretion to facilitate people who, even though they do not satisfy the income limits, have a particular medical situation that is impacting on their financial situation. We cannot do it in any other way. Neither the Minister for Health or I or the HSE can override the legislation. We cannot say that from now on we will give a medical card on the basis of a medical illness or condition. We simply cannot do it and we would need to change the law to do so. If people come forward and say that is what we should do, that is fine, but unless or until we decide to do that-----

You are changing the law.

We are changing the law to adjust the eligibility for medical cards. I am genuinely interested in people's views. Is it being proposed by Deputy Kelleher or anyone else in the House that we should change the 1970 Act in that radical way to move it away from an assessment of means to an assessment of medical condition? I will not press Deputy Kelleher to respond but if that is the view he or anyone else has, let us start debating it because it would be a fundamental change in the way we allocate medical cards. Maybe we should look at it. I do not think it would be the right way to proceed. I think we should go for full universal access to GP services as quickly as we can achieve it for the whole population because there is a significant public health reason for doing that as well. Ultimately, it is the only way we can get away from people having to go through mean testing and applications for discretionary medical cards when, in a civilised society, we should have universal access for all people to a basic primary care service. That is the view I have and the view I believe the Government has, which is why we are implementing the measures we have announced.

I will respond, in no particular order, to some of the issues raised. Deputy Terence Flanagan raised the issue of data sharing. I assure him that we have made considerable progress in respect of data sharing between the HSE, the Department of Social Protection and the Revenue Commissioners. The powers to do that were in the parallel legislation from earlier this year arising from last year's budget when we made changes affecting the over 70s. The Deputy may recall that there were provisions in that legislation facilitating the exchange of data between those bodies, and that is moving ahead. It is good that this opportunity exists.

Deputy Calleary was very fair in what he said. He accepted that while there are sometimes difficulties in respect of the administration of the scheme, the HSE and PCRS staff who are administering it are working well, are approachable, are doing the best they can to administer the system and are doing so professionally. I thank him for acknowledging that. He again raised the issue of cards being taken away. He said someone, possibly a constituent, went to the doctor and was told their card was gone. It really troubles me if this is happening. There is no reason somebody should be surprised by an announcement by their doctor that their card has been taken away because people are written to three months in advance of there being any change and again a month in advance. I will not stand here as Minister of State and say this would never happen because I know it is a human situation and things go wrong, but it should not happen as long as the person who receives the letter engages with the HSE, and there seems to be no reason it should happen.

A constituent of mine contacted me in recent weeks with a similar situation but it turned out that it was simply a bureaucratic mistake. The person had been in hospital for a lengthy period, came out, went to see her doctor and was told she had gone off the system. Due to the fact that she had been in hospital, she presumably had not been receiving mail and there had been no engagement. There was no loss in that situation.

It is important that people engage with the system and I think people are doing so. Deputy Calleary said that the PCRS should ensure it contacts the Irish Cancer Society and motor neurone disease advocacy groups, and this is happening. I encourage this to continue happening and I agree with him that it is important. In respect of medical decisions being made without the doctor ever seeing the patient, I repeat the point I made earlier. It is not a medical examination in the way we understand it for the purposes of a diagnosis or medical report. That is not the involvement of the doctor in the system of discretionary medical cards. For the purposes of clarity, the discretionary medical card may be awarded to an individual in circumstances where paying for his or her medical costs may cause undue financial hardship, for example, an ongoing medical condition that requires exceptional and regular medical treatment or visits to the doctor or hospital. If doing so would cause undue financial hardship, because this is still the test, a card may be granted by the HSE on a discretionary basis even though the person is in excess of the income guidelines. The HSE set up a clinical panel at the Minister's request some time back to assist in the processing of applications for discretionary medical cards where there are difficult personal circumstances which ensure the applications by those diagnosed with ailments such as cancer are assessed and addressed in the most expeditious and sensitive way. In respect of what Deputy Calleary said, it is not about a medical decision or diagnosis per se. Input is probably a better word to describe it. It is the medical input of a doctor to endorse the fact that the medical expenses are reasonably associated with a particular medical condition the person has.

Deputy Healy-Rae made many points and I listened carefully to him. He alleged that a secret decision had been taken to take 40,000 cards out of the system. I am not aware of any secret decision. I suppose if it is secret, I probably would not know about it but I certainly was not let in on any such secret. A decision was taken last year which had an impact on 40,000 medical cards. Of these, 20,000 belonged to over 70s - this was last year's change relating to the over 70s - and 20,000 belonged to the under 70s where certain adjustments in respect of the allowable expenditure in the assessment of under 70s were made. Perhaps that is the 40,000 to which the Deputy is referring. If it is, it was no secret and it was certainly no secret in this House because it was debated and we were criticised for it many times.

Deputies Wallace and Lowry referred to the following point. Deputy Wallace thinks that what we are doing is contradictory and confusing. He mentioned the views of certain organisations, including some doctors, that we should not be doing this. I am not sure if this is Deputy Wallace's view because he then agreed with the value of a universal system. Some people have said we should not be giving medical cards to children under six whose parents are wealthy. The majority of people who will benefit from under-sixes getting the medical card are not wealthy people. They are not millionaires. They are people on low and middle incomes. If one looks at the profile of those who qualify for medical cards at the moment and the profile of people above that who do not qualify, one will see that the majority of the people in this State whose children will benefit from the medical card are very far from being millionaires.

We come back to the point about targeting and universality. It is a discussion we need to have in this House about the medical service. Do we want to have universal access? Do we believe a properly functioning primary care service and health system should contain access to one's doctor without having to pay fees with all that can entail for improving one's own health, preventative health strategies and the management of chronic illnesses - all the things we have been talking about in this House for more than ten years or perhaps 20 years? They include the necessity of promoting primary care. We need to take away the barrier of fees. We will never solve the problems in the health service if we do not reallocate resources and adjust our perspectives towards primary care. Everybody in the House agrees with that. If we agree with that in principle, we must start the process of achieving it. I sometimes pause when people say this is not the right time to do it. Deputy Kelleher might not have said it but others have. They say we should do it in the future. I disagree passionately with that because I think that even though we are facing financial constraints and must make these decisions in this legislation and other things that nobody likes, we should make a start on this big project of universal access to primary care.

I see the decision on the under six year olds as part of that. I do not see it as a political stunt, a once-off or a sop, as it has been described by some, because it is not. It only makes sense as part of a project to extend universal access to primary care services to the entire population, and I passionately believe that is what we must do as a Government and Oireachtas. We must start to deliver on this policy imperative and principle that we all say we share, so it is not contradictory. It is true we are obliged to plug many leaks in the existing system and that there are many pressures and difficulties in that system, but we must start looking to the future as well and try to do the two at the same time. I believe we should make a modest start on this, then look to see where we go next and find the best way to deliver the laudable objective of universal access to primary care. There is no other way to solve the problems in the health service. No country in the world would be able to solve the problems in the health service and the challenges of an aging population, chronic illnesses and the other problems that already exist, with more coming down the tracks, without doing this. The very welcome decision by the Government on the under six year olds is a key step towards delivering that.

Deputies Shortall, McConalogue and Keaveney referred to the arrangements for the over 70 year olds not taking account of medical expenses on the basis that it is a gross income assessment. A person over 70 years of age who faces large medical expenses can also apply to be assessed under the standard means assessment for medical cards for the general population. That assessment takes account of housing, travel to work, child care and medical expenses.

I dealt with the point raised by Deputy Clare Daly. Deputy Browne said it is very difficult or impossible to obtain an end-of-life medical card within one to two weeks. The HSE has special arrangements in place to issue an emergency medical card for a person in palliative care with a terminal illness. It will be issued within 24 hours. It would trouble me if there were cases where that is not occurring. I cannot swear, hand on heart, this always works as well as we would like on every occasion, but I know from the many cases of which I am aware that it is working. I hope that is so generally and that it remains to be case.

I will conclude with the remarks made by Deputy Cowen. His critique of the Government in the broader sense, and Deputy Healy-Rae and others made similar points, was largely about what was said before the election and what is happening now. It was in that category of contributions. It is difficult for Deputy Cowen to criticise the Government in one sense because, in the next breath, he or his colleagues say we are implementing the agreement made by the last Government before the election. It is difficult for people to criticise us for doing something they say they would have done anyway.

It is the choices.

Social protection is an interesting example of the choices. We know from the Fianna Fáil numbers in the four year plan prior to the last election that the people were far better advised to choose this Government in respect of social protection. If the party opposite had gone into government, the cuts that would have occurred in social protection - this is from its own words before the election - would have been many hundreds of millions of euro worse. Not to choose the Fianna Fáil way, which would have been deeper social welfare cuts than would ever have happened under this Government, was a very good choice by the Irish people. That is not just rhetoric on my part but is based on that party's own numbers. Deputy Kelleher is right in respect of choice.

We were honest about it.

I can agree to an extent with Deputy Cowen in respect of the discussion on the future and how we approach it. Deputy Cowen probably does have a point with regard to how we all debate and discuss the future, now that we are emerging from the traumatic crisis we have been in for the past number of years. We must think more carefully about what we say we can achieve in the future and what is achievable in the country. We must look at what undertakings we make in future election campaigns. All of us need to take care with regard to how we assess the possibilities and how we say we will raise revenue to provide certain public services. The politics of the promise is an interesting concept for examination by all sides of the House. Perhaps we all need to look at how best we can have a good public political discourse in the future. I have no difficulty with that. A certain amount of humility all around the House might go a long way. As we look to the future we should do so in an honest fashion and we should be able to show people precisely how we will achieve what we want to achieve, such as, for example, universal access to primary care.

I am still waiting for Deputy Kelleher to say whether he agrees with the announcement on children under six years of age. I know Deputy Ó Caoláin agrees with it, but I am not sure yet about Deputy Kelleher. Perhaps he will tell us one of these days whether he agrees with it. Regardless of whether he does or not, he will agree that we must be careful and honest with the people in terms of looking to the future.

I believe this Government has striven effectively to limit the worst excesses of what could have occurred and was intended to happen in the bailout years. We have achieved a great deal in terms of taking the worst edges off the cuts and revenue increases that were necessary to bring the public finances into order.

The measures in this legislation are not ones that anybody wishes to be obliged to propose, to row back on an entitlement that was given to a certain group. However, it has been done in the best possible way in terms of ensuring fairness. A relatively small number of people are affected and, most importantly, 93% of the over 70 years of age cohort will still have access to free GP care.

Question put:
The Dáil divided: Tá, 79; Níl, 46.

  • Bannon, James.
  • Barry, Tom.
  • Bruton, Richard.
  • Burton, Joan.
  • Butler, Ray.
  • Buttimer, Jerry.
  • Byrne, Catherine.
  • Byrne, Eric.
  • Cannon, Ciarán.
  • 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.
  • Deenihan, Jimmy.
  • Deering, Pat.
  • Dowds, Robert.
  • Doyle, Andrew.
  • Durkan, Bernard J.
  • English, Damien.
  • Feighan, Frank.
  • Fitzgerald, Frances.
  • Fitzpatrick, Peter.
  • Flanagan, Charles.
  • Griffin, Brendan.
  • Hannigan, Dominic.
  • Harrington, Noel.
  • Harris, Simon.
  • Hayes, Brian.
  • Howlin, Brendan.
  • Humphreys, Heather.
  • Humphreys, Kevin.
  • Keating, Derek.
  • Kehoe, Paul.
  • Kelly, Alan.
  • Kenny, Seán.
  • Kyne, Seán.
  • Lawlor, Anthony.
  • Lynch, Ciarán.
  • Lyons, John.
  • McCarthy, Michael.
  • McEntee, Helen.
  • McGinley, Dinny.
  • McHugh, Joe.
  • Maloney, Eamonn.
  • Mitchell O'Connor, Mary.
  • Mulherin, Michelle.
  • Murphy, Dara.
  • Murphy, Eoghan.
  • Nash, Gerald.
  • Neville, Dan.
  • Nolan, Derek.
  • Noonan, Michael.
  • O'Donnell, Kieran.
  • O'Donovan, Patrick.
  • O'Dowd, Fergus.
  • O'Mahony, John.
  • O'Reilly, Joe.
  • O'Sullivan, Jan.
  • Perry, John.
  • Phelan, Ann.
  • Phelan, John Paul.
  • Rabbitte, Pat.
  • Reilly, James.
  • Ryan, Brendan.
  • Spring, Arthur.
  • Stagg, Emmet.
  • Stanton, David.
  • Tuffy, Joanna.
  • Walsh, Brian.
  • White, Alex.


  • Boyd Barrett, Richard.
  • Broughan, Thomas P.
  • Browne, John.
  • Calleary, Dara.
  • Collins, Joan.
  • Collins, Niall.
  • Colreavy, Michael.
  • Cowen, Barry.
  • Daly, Clare.
  • Doherty, Pearse.
  • Donnelly, Stephen S.
  • Ellis, Dessie.
  • Ferris, Martin.
  • Flanagan, Luke 'Ming'.
  • Fleming, Sean.
  • Fleming, Tom.
  • Grealish, Noel.
  • Halligan, John.
  • Healy, Seamus.
  • Healy-Rae, Michael.
  • Higgins, Joe.
  • Kelleher, Billy.
  • Kirk, Seamus.
  • Lowry, Michael.
  • Mac Lochlainn, Pádraig.
  • McConalogue, Charlie.
  • McDonald, Mary Lou.
  • McGrath, Finian.
  • McGrath, Michael.
  • McGuinness, John.
  • McLellan, Sandra.
  • Martin, Micheál.
  • Mathews, Peter.
  • Moynihan, Michael.
  • Murphy, Catherine.
  • Ó Caoláin, Caoimhghín.
  • Ó Cuív, Éamon.
  • Ó Fearghaíl, Seán.
  • Ó Snodaigh, Aengus.
  • O'Brien, Jonathan.
  • Ross, Shane.
  • Shortall, Róisín.
  • Smith, Brendan.
  • Stanley, Brian.
  • Troy, Robert.
  • Wallace, Mick.
Tellers: Tá, Deputies Paul Kehoe and Emmet Stagg; Níl, Deputies Seán Ó Fearghaíl and Aengus Ó Snodaigh.
Question declared carried.