I move:
That Seanad Éireann approves the following Regulations in draft:
Health Services (Limited Eligibility) Regulations, 1979,
a copy of which Regulations in draft form was laid before Seanad Éireann on 14th March, 1979.
Health Services (Limited Eligibility) Regulations, 1979: Motion.
The purpose of these regulations is to change the rules governing limited eligibility for health services with effect from 6 April 1979.
At present, persons with limited eligibility for health services are persons, other than those with medical cards, whose rate of pay or income is within a limit of £3,000 or, in the case of farmers, whose valuation is £60 or less. There are many exceptions to this definition, however, related to the type of work performed, social welfare insurance status and other factors which have little relevance to a person's ability to pay for health services.
The health services which are specifically available to those within the present definition of "limited eligibility" are:
—hospital services, both in-patient and out-patient, together with subsidies towards the cost of maintenance in approved private hospitals and homes;
—maternity and infant welfare services;
—a drug subsidy scheme.
The effect of the draft regulations now before the Seanad will be to allow benefits within this range to be extended to the entire population. The delineation of the benefits to be available to each group of the population will be made in separate regulations under section 72 of the Health Act, 1970.
These regulations will not require the prior approval of the Houses of the Oireachtas but I should at this stage tell the House what I intend to include in these regulations, as well as what is dealt with in the draft before the House.
The combined effect of the two new sets of regulations will be that services will be available for three categories of the population.
Category I will consist of persons with medical cards who have full eligibility for all health services. No change is being made in the composition of this category or in its entitlement to health services. Somewhat less than 40 per cent of the population is in this category.
Category II will consist of all persons, other than those in category I, whose income in the year ending 5 April 1979 was less than £5,500. Persons in this category will be entitled without charge to the full range of "limited eligibility" services, that is, hospital in-patient and out-patient services, maternity and infant welfare services and the drug subsidy schemes. About 45 per cent of the population is in this category.
Category III will consist of persons whose income in the year ending 5 April 1979 was £5,500 or more. Persons in this category will be entitled to hospital services on the same basis as for those in Category II except that they will be liable to pay consultants' fees. They will also be entitled to participate in the drug subsidy scheme. Somewhat over 15 per cent of the population is in this category.
In addition to the services which I have described and which will be available specifically to persons within the relevant category, there are services at present available to the entire community without reference to income. These include in particular:
—immunisation and diagnostic services and hospital treatment for infectious diseases;
—hospital in-patient and out-patient services for children suffering from mental handicap and mental illness and from a number of other long-term conditions;
—prescribed medicines without any charge for all persons suffering from a number of long-term diseases and disabilities.
These services will continue to be available to the entire population.
The changes in entitlement to health services are being made in association with the introduction of a system of income-related health contributions as provided for in the Health Contributions Act, 1979. This system, which will operate from 6 April 1979, will change the present system of flat-rate health contributions to one which will be income-related. The rate of contribution will be 1 per cent of income subject to a maximum contribution of £55. Persons in category III will pay the maximum contribution. Persons in category II will pay a contribution which will be graded with size of income: the smaller the income, the smaller the contribution. Persons in category I will not be required to pay any contribution.
The changes which I now propose to make represent a major extension of entitlement to health services.
At present, an income limit of £3,000 operates for purposes of entitlement to hospital services and other "limited eligibility" services. Under the new arrangements this limit will be abolished
for hospital in-patient and out-patient services, other than consultants' fees;
—for entitlement to subsidies towards the cost of maintenance in approved private hospitals and homes;
—for the right to avail of the drug subsidy scheme.
In future, everybody will be able to avail of these services without reference to income.
At the same time, the £3,000 limit is being increased to £5,500 for purposes of entitlement to the services of hospital consultants and to maternity and infant welfare services from general practitioners.
This new limit of £5,500 relates to income for the year ending 5 April 1979. It will apply throughout the following year, that is during the year up to 5 April 1980. Before that date it will be reviewed having regard to changes in incomes and it will be increased again if cimcumstances warrant this.
This limit of £5,500 will also apply to farmers. In their case, income will in most instances be calculated by reference to rateable valuation.
In the case of a married couple, each of whom has a separate income, the entitlement of each will be assessed separately. I have given some thought to the question of the entitlement of children in such cases. I have decided that if each parent, on an individual assessment, is deemed to be in category II, the children will also be eligible for category II services, even though the combined incomes of the two parents may exceed the £5,500 limit. If, on the other hand, either parent is in category III the children will also be regarded as being in that category. To arrange it otherwise would be inequitable in relation to families in which only one parent has an income.
I have had a number of discussions with the Irish Congress of Trade Unions and with the medical organisations concerning this limit and its operation. I had originally proposed that the limit should be fixed at £5,000 but having regard to the increase in average industrial earnings shown in the latest figures available, that is March 1978, and having considered representations which were made at the meetings with congress I increased the limit to £5,500. This means that 83 per cent of the population will be within the limit. In considering this limit, it should be borne in mind that eligibility in any year will be based on earnings in the previous year.
I believe that these arrangements provide the right mix of public and private health care systems for the population having regard to the excellent service provided by the Voluntary Health Insurance Board. As 700,000 people participate in the boards schemes, and this number is increasing all the time, it is clear that a large section of the population want to have the option of private care.
Finally, on the limit chosen—£5,500 a year—I would point out that it is a very real improvement of the present figure of £3,000 a year. Were we to have adjusted that on the traditional basis, it would have become merely £4,500 a year.
As well as being a major extension of eligibility, the changes which I now propose will remove a number of complexities and anomalies which had developed in the present rules of eligibility. It was necessary to adapt the rules at various times in the past to meet the requirements of changing circumstances. As a result, the criteria of eligibility have become complicated and many people have difficulty in understanding their entitlement. There is also the fact that the eligibility rules, as originally devised, made a distinction between manual and non-manual workers and between different categories of social welfare insurance. Whatever justification there may have been for these distinctions in the past, they are now totally irrelevant to the question of ability to pay for health services. Their removal will mean that the question of ability to pay for health services will be decided by reference to actual income and this criterion will apply uniformly for the entire population.
It is inevitable that if these anomalies were to be removed some people must lose part of their present entitlement. This is unavoidable if the same criteria of entitlement are to have equal application for everybody. There is no reason, however, why this loss of entitlement should cause serious problems. The major part of hospital costs is the charge which may be made by the hospitals. In some cases, this can be a serious burden on an individual but, under the arrangements which I am now introducing, nobody will be forced to meet this charge. In addition the hardship provisions, under which the chief executive officer of a health board can arrange for the provision of services in any case which would otherwise result in hardship, will continue to operate.
There is also the very important fact that the Voluntary Health Insurance Board is revising its scheme of insurance to provide that insurance cover for medical fees will be available to everybody. For a modest premium any person who wishes to do so will be able to fully insure himself against the risk of any medical expenses which might arise during a spell of hospital treatment. The board will also provide that current restrictions, related, for example, to age or to existing medical conditions, will be waived for a time to enable everybody to avail of this insurance cover.
The value of voluntary health insurance is clearly seen from the fact that over 700,000 people are now covered by this form of insurance. What I would like to stress in particular is that voluntary health insurance should not be the prerogative of any one sector of the population but should be capable of being availed of by all. The revised schemes offer many benefits and choices and I would urge everybody to study what is being offered to see what is available to suit their circumstances and needs.
It can be seen, then, that the changes which I now propose to make will have two important consequences. In the first place, they involve a major extension of entitlement to health services which will ensure that in the future nobody need fear the financial consequences of serious illness. In the second place, they will remove the inconsistencies and inequities which have developed in the present rules of entitlement: everybody should be clear on his entitlement and nobody need feel that he is being treated unfairly relative to the rest of the community.
In welcoming these regulations we must admit that they are an advance on the situation which applied hitherto. There were certain anomalies which were beyond comprehension in many instances. The anomaly between manual and non-manual workers has been removed under this new scheme. There is at least some cover for everybody now. While the ultimate objective is for a free and comprehensive scheme—this is a considerable distance away from being that—this scheme is still welcome. The scheme carries signs of compromise. The previous Minister for Health ran into considerable difficulty in regard to the consultancy aspect of such a scheme and it appears there have been some signs of compromise in regard to the operation of these new regulations, namely, that consultants will have a certain amount of their business still applicable to them.
It is regrettable that there has to be a demarcation of £5,500. The Minister indicated in the Social Welfare Bill that he has certain limitations in regard to benefits. I have to accept that he is again limited in regard to what he can do under these regulations. It is good to see that the Minister can and will I hope, review this figure at the end of 12 months. Certainly, once the figure is linked, as it has been in these regulations, to average industrial earnings, one can see an increase in the figure of £5,500 in the next 12 months. There has always been a regrettable aspect in regard to any ceiling figure, and that is that it has been inclined to remain unadjusted for far too long. We have seen this in operation in very many other schemes apart from the health field. It applies to housing where there is a limit in income earnings, on loan ceilings and so on. These figures are not changed as regularly as they should be.
In regard to the three categories of people who will benefit from these regulations, the first category, those who are eligible for medical service cards, will continue as hitherto. I always thought that there was an unofficial instruction from the Department of Health and Social Welfare to the various health boards to keep the percentage of the population who possess medical cards somewhat below 40 per cent. Over the years the figure has never gone beyond 40 per cent. It veered between 35 per cent and 40 per cent. In regard to the medical cards, I appeal for a more flexible assessment in determining whether a person is eligible or not. There have been very many hardship cases. There is a clause in regard to the regulations under which health boards are supposed to take into account particular cases of hardship. Regrettably these do not seem to have been adhered to in a number of instances.
Many efforts have been made to have asthmatic sufferers automatically included as eligible for medical service cards. These people merit more favourable consideration in their application for medical cards than they have received.
The present income ceiling is £40 for a married couple which is not over-generous in the age that we live in. There has been a minimal increase on 1 January each year since the medical card scheme came into existence. Percentage increases each year are well and good but if the basic figure is not adequate in the first instance it means that the income figure is always lagging behind. A £40 income limit for a married couple is not over-generous at this time.
Regarding the category II people who will benefit under these regulations, the contribution required from them has been doubled from £26 per annum to £55. They do not appear to be getting a commensurate increase in benefits for that extra contribution and perhaps the Minister would enlighten me if that is not the situation.
In regard to the category III people, these appear to be excluded from maternity services and they will certainly have to pay consultancy fees. As there are only 15 per cent in this category I wonder why it has not been found possible to consider them for maternity services and the payment of consultancy fees. Perhaps the Minister would let me know how much it would cost to include this 15 per cent of the population.
I should like to compliment the VHI on doing a wonderful job. They have come to the assistance of many families. Their reaction to the changes in the regulations is to their credit. They have introduced changes in their existing schemes for which they are to be complimented. The former Minister for Health ran into difficulty in regard to the consultants, namely that they said there would not be enough hospital beds. That was one of the arguments they outlined in their opposition to his scheme. Has anything happened in the meantime to ensure that there will be an adequate number of hospital beds for everybody who seeks hospitalisation? I welcome these regulations. There are still a number of things which will leave it short of being a full and comprehensive health service for everybody but it is an advance towards that objective.
I welcome the regulations which are a further excellent improvement on our health services. The actual benefits have been very considerably extended. There have been up to now, two alternative arrangements for health services. One was the system of private medicine exemplified by the practice in the United States often resulting in excellent but limited services, limited both geographically and in the number of people able to afford proper health care. There is the dreadful situation of people taking ill when abroad, and not only suffering from their illness but also from distress, financial embarrassment and perhaps even total financial inability to pay either for themselves or their dependants for necessary medical treatment.
We have the other alternative as exemplified by the national health service in the United Kingdom, an absolutely excellent concept and one, which in practice, has meant availability of health services to the population as a whole but, in effect, a rationing system and a continued deterioration in the actual care available to an individual when ill, an inevitable situation perhaps in view of the method of financing and of the openendedness of the British system. It is very difficult to strike a mean between these two. We naturally wish to provide all possible health services at as high a standard as possible for our population. At the same time we want to ensure that these services are readily available and that one does not have to wait months or perhaps even years for a very necessary operation.
We have managed, and the Minister is to be congratulated on this, to strike a balance whereby the eligibility for services has been vastly increased and the fear of the financial consequences of being ill has for the first time been removed. This is a very great advance and one which is put too modestly by the Minister. At the same time, as was pointed out, there is a very definite desire for private health services. There is no doubt that the provision of private health services sets an example and puts a competitive edge on health services which ensures that both private and general health services tend to increase in quality rather than decline. We must compliment the VHI for their excellent work and compliment the Minister for the very good blend which he has managed to produce in his regulations. I join with other Senators in welcoming this motion.
I am grateful to Senators who have spoken and for the welcome they have afforded this measure. It is an important step in the general structure of both health and social welfare services which will come into operation on 6 April next. They represent a major step forward and should be of very great benefit to the community as a whole and particularly to the unfortunate section of the population who require hospital services from time to time.
I was speaking last night to the Mental Health Association of Ireland at a seminar they were organising and I pointed out to the members that things are not going very well in regard to the general health of the nation. I gave the statistic that in 1977 one in every six people went into hospital. There were a number of other statistics which we can also enumerate to indicate that health is not improving. That may be an over-simplification. Some of the figures I gave yesterday evening may reflect that people are getting better attention now. In the old days people who were ill and who could have benefited from hospital services did not avail of them because for financial or other reasons they were afraid to. In so far as these regulations which we are now initiating are concerned the burden of the cost of health services will be removed from the whole population.
Medical cards are always a subject of interest to Deputies and Senators. Senator Markey referred to the situation in regard to eligibility for medical cards. I want to assure him and other Senators that there was no direction given in this regard as far as the health boards are concerned.
I had a recent meeting with the chief executive officers and went over the whole ground. They understand that it is their responsibility to make medical cards available to any individual or family who cannot provide medical attention for themselves without hardship or who because of their circumstances, are prohibited from providing for their own needs. There is no question of any secret or implicit or any other sort of direction so far as the health boards are concerned. There is always, of course, a problem about medical cards, particularly in marginal cases. There is room for dispute I suppose between the medical officer of the health board and the individual and his family as to whether or not their income situation is such that they come within the guidelines. I have asked the chief executive officers to be as flexible as possible in the administration of the guidelines. I pointed out to them the provision about hardship and they assured me that they have no inhibition whatever in using that particular provision when circumstances dictate.
The provision, as is seldom known, has the effect that, irrespective of guidelines or anything else, if there is any particular case of hardship where some medical service or attention is required by an individual or a family which they cannot provide without inflicting hardship on themselves, then at the chief executive officer's complete discretion the health board may provide for that situation. The most common situation that has occured is where somebody has to go abroad for a particular type of treatment or operation; health boards are, in fact, to give chief executive officers full discretion to make assistance available in that sort of case. They also have the discretion to make a medical card available for an individual member of a family for a short period, if that is considered necessary or desirable in the particular circumstances.
Senator Markey also mentioned the asthma sufferers. They are a very important sector of our community and a sector with whom we have a great deal of sympathy. I have talked in some detail to them about their problems and we hope to improve their situation, generally. There are difficulties in adding them to the list of long term illnesses which is, I suppose, the ideal solution as far as they are concerned. Short of doing that, we were able to tease out with them a number of alternative ways of coming to the assistance of the asthma sufferer.
On the question of maternity fees for category III, the situation is quite straightforward. The person in category III will be entitled to free hospitalisation for maternity purposes. If the woman concerned goes into a public ward she will be entitled to completely free hospitalisation and all ancillary services; in so far as she may wish to avail of semi-private or private accommodation she will get the approved allowances. People in category III will be responsible for the consultant's fees for maternity, but side by side with this, the Voluntary Health Insurance Board are now bringing in a new scheme covering consultant's maternity fees. I would very strongly advise Senators who are in a position to do so through their constituents and the voluntary organisations and bodies of which they are members to direct attention to this free service by the Voluntary Health Insurance Board.
Senator Conroy and Senator Markey both paid tribute to the Voluntary Health Insurance Board. The whole principle of voluntary health insurance and the operation of the board is one of our great success stories in modern times in the health area and, indeed, it shows the value of the principle of insurance. We should take it as a headline for many other areas and see how this principle of insurance can be applied in other areas, because it has worked out so successfully in the case of health insurance.
The new schemes which the voluntary health board are bringing in must be of enormous interest to a very wide section of the people. I want to try to kill the idea that voluntary health insurance is something for the professional class or for the higher paid, white collar salaried worker. I want to get it across that this service is available for the general public; particularly I want to see higher paid workers coming into voluntary health insurance. I feel that if we could get the message across to wives that these maternity services are now available under the voluntary health they would all join the insurance scheme fairly quickly.
I am glad Senators paid that tribute to the Voluntary Health Insurance Board. I hope during the course of the coming year we shall see an enormous extension of the membership of the voluntary health insurance system. I am grateful for the reception afforded to these regulations by the Senators. I shall bring them into the Dáil next week. I brought them to the Seanad in the first instance so, to that extent, the Seanad can claim credit for having them initiated here.
I would like to take this opportunity to put a question to the Minister in regard to the drugs——
The Senator may ask a question.
In regard to the drugs subsidy scheme, would the Minister consider some alleviation in regard to the conditions applicable under this scheme? It now applies to categories I, II and III. People in category I are quite safe with it, but in the case of category II, these would be people under the £5,500 ceiling. It has been my experience that they can encounter certain difficulty——
It is only a question.
I must elaborate on the question first of all. A married couple with, say, £45 a week, are not covered by a medical card; therefore they come into category II. In my experience these people have found it difficult to go into this scheme because straight away they have to find the money to buy drugs and medicines, under this drug subsidy scheme. There is always a delay in the recoupment and it is my contention that the percentage refund is not by any means over-generous; my belief is that a greater incentive should be offered to people under this scheme. Would the Minister consider, perhaps, a graded percentage incentive for the different families? You could have a married couple, say on £45 or £50 a week, as against a married couple on £100 a week just below the ceiling of £5,500 in the year; there is considerable difficulty experienced according to the different incomes that the families may have.
I take the point. I certainly have looked at this sort of scheme; a number of aspects of it do require looking into and we have been doing that in the Department and discussing it with other sections, and again I come back to the asthma sufferers; one of the points they made was that, unfortunately for them, their drugs bill was pretty regular and it was a bit of hardship for them to have to wait to be reimbursed. I discussed that with the CEO's to see if we can do something for them, or people like them, who spend a more or less fixed amount on drugs, month by month by month, to see if we can do something to relieve their burden. I think we might be able to come up with something. I agree also that the limits do need looking at. The only thing about them is that the present limit of £6.50 with the flux of time will become easier. Whether we can do a bit more or not we shall have to see.
Yes. The Minister does accept the point I made, that there is considerable difficulty for a family, a married couple with only £45 or £50 a week income who have not a medical card cover, who must resort to this drug subsidy scheme. They find it much more difficult, naturally, to find the money to buy the drugs——
For regular bills, for people who have regular bills as against a family who have £100 per week.
Yes.
Question put and agreed to.
The Seanad adjourned at 4.40 p.m. until 2.30 p.m. on Wednesday, 28 March 1979.