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Seanad Éireann debate -
Thursday, 5 Dec 2013

Vol. 228 No. 3

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

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

I wish to outline the Health (Alteration of Criteria for Eligibility) (No. 2) Bill 2013 to the Members of Seanad Éireann, and I look forward to hearing the views of the Senators in the course of the Second Stage debate. The Bill amends the Health Act 1970, as amended, principally section 45A and section 48A, to take account of the changes to the eligibility criteria for medical cards for persons aged 70 years and over, as announced in budget 2014.

The 2014 financial provision for the health services is €13.66 billion, including €397 million in capital expenditure. This provision also includes savings measures amounting to €666 million. This is some €360 million less than was provided in 2013, and represents a 3% reduction in funding. As a result, 2014 will be the most challenging year the health services have yet had to face. I assure the House, however, that maintaining safe, quality health services will be as much a priority for the Government in 2014 as it has been in 2013, despite the need for significant and difficult financial savings. It has been, and most assuredly continues to be, our intention that front-line health services would be protected to the greatest extent possible, and I have made clear that providing safe, quality services in a timely fashion is my top priority.

We continue to build on the ongoing measures to achieve savings through efficiencies and reorganisation under the public service agreement, to curtail the growing cost of pharmaceuticals, and to increase income generation. None the less, the level of savings required means the Government has had to make some very difficult decisions and all of us, personally, and as public representatives, are well aware of the vast impact of these difficult decisions forced upon us. The Government continues to ensure we reduce the cost of services while maintaining safe services to ensure the most vulnerable are protected.

The General Medical Services, GMS, scheme, is one of the areas identified in budget 2014 for required savings. As the Senators are aware, the GMS scheme comprises general practitioner, GP, services and prescription drugs, as well as some other services provided to holders of medical cards or GP-visit cards. Over recent years there has been a significant expansion in the GMS scheme. The GMS costs in the region of €2 billion per year, and several steps are being taken to reduce this cost. At the end of October 2013, approximately 1.99 million people qualified under the GMS. Medical cards make up most of this number, amounting to 1.86 million or more than 93% of the total. At the end of 2005, there were 1.16 million medical cardholders. Since then has been an increase of more than 60% in the number of medical cards, amounting to 700,000 individuals. In excess of 40% of the population now holds a medical card, compared with just 27% at the end of 2005. Medical cards for persons aged 70 years and over account for approximately 350,000 individuals, or approximately 19% of all medical cards. The total cost of the GMS provided to over-70s medical card holders is approximately €750 million per year, which represents more than one third of the total cost of the GMS scheme.

Under the Health Act 2008, special eligibility rules applying to persons aged over 70 years were put in place which are more generous than those applying to the standard means-tested medical cards. It is estimated that there are approximately 379,000 people aged over 70 years in the State. Given that there are approximately 350,000 medical cards issued to people aged over 70, medical card coverage of the over-70s population is approximately 93%. In comparison, the medical card coverage of the under-70s population is of the order of 36%.

In the recent budget, changes to the over-70s eligibility criteria were announced to deliver €25 million in savings during 2014 from the expenditure on over-70s medical cards, which is in the region of €750 million annually. Under this proposed legislation, the income limit for an over-70s medical card is to be set at €500 per week, equivalent to an annual income of about €26,000, for a single person. For a couple, the income limit for the over-70s medical card is to be set at €900 per week, equivalent to gross annual income of almost €47,000.

Those affected by these revised thresholds will qualify for an over-70s GP-visit card. A single person aged over 70 with a gross income of up to €700 per week, or approximately €36,000 per year, will continue to qualify for free access to a GP. A couple over 70 years of age with a gross income of up to €1,400 per week, or approximately €72,000 per year, also qualify for a GP service without fees. In addition, under the drugs payment scheme, DPS, the HSE will meet the prescription drug costs of older people without a medical card who face drugs costs higher than the DPS threshold of €144 per month. This means that a single person aged over 70 with a gross income in excess of €500 per week or a couple with an income in excess of €900 per week will have to pay no more than approximately €33 per week on prescription drugs.

It is estimated that approximately 35,000 people will have their medical card replaced with a GP-visit card under the new income rules. It is necessary to reassure people in their 70s and older that we are implementing this measure in a manner that is intended to avoid affecting the most vulnerable of our elderly population. Out of every five people aged over 70, the four poorest will not be affected by this budget measure. Therefore, it is useful to note that 10% of those aged over 70 who previously qualified for a medical card will now qualify for a GP-visit card instead. Every person aged over 70 living on the State pension alone will still qualify for an over-70s medical card. The new income limits for over-70s medical care is more than twice the level of the basic State pension of €230 per week for a single person and €436 per week for a couple. Therefore, following implementation of this budget measure, just 7% of over-70s, those with the highest incomes, will not qualify for either a medical card or a GP-visit card. In other words, 93% of over-70s will continue to be covered for free GP care, either through a medical card, which would be the bulk of that group, or a GP-visit card.

As I stated, there has been a significant expansion in the GMS scheme and, while the rate of increase in the numbers of people with eligibility under the GMS scheme has declined, the overall number of people with eligibility has increased. We must ensure those most in need can qualify for the service. We have an obligation under the legislation to ensure the State is not paying for a service for those who are no longer entitled because their situation has improved. To this end, a critical element of probity in the medical card scheme is the ongoing review of client eligibility by the HSE. Senators are aware that, under budget 2014, medical card probity measures were announced whereby significant savings are to be achieved by improving the accuracy of the medical card system. This is intended to ensure those who are entitled to medical cards continue to hold them and those who are not entitled to medical cards do not.

I am aware there has been public concern that cards may be indiscriminately withdrawn or cancelled. This concern or perception is similar to the misconception that cards awarded on a discretionary basis are being withdrawn or refused arbitrarily. This is not the case. Let me put it on the record, to dispel any misconceptions that might still exist, that in line with the legislation, there has never been an automatic entitlement to a medical card on the basis of having a specific illness or condition, there has been no change to the policy on discretionary medical cards in the past year, the scheme continues to operate in such a way that those who suffer genuine financial hardship as a result of a medical condition receive the benefit of a medical card, and notwithstanding the need to secure savings under the medical card scheme, nobody who is entitled to a medical card will lose it or be refused one. I stress again that no person meeting the eligibility conditions laid down in the legislation for a medical card will be affected.

We want people to be clear on their entitlements and this should help ease the fears of those who have been worried unnecessarily. To this end, the HSE devised a wide-ranging plan to improve the provision of information to the public about medical cards. On 30 October last, the HSE announced a communications campaign designed to raise awareness of the rules governing eligibility for medical cards. This is just one example of how this Government is focused on improving the health service. While it may not be affordable to provide medical cards to the entire population, this 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 in the Future Health strategy framework.

The introduction of a universal GP service free at point of use constitutes a fundamental element in the Government's health reform programme and the 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 universal health insurance and eliminating the two-tier health system.

As announced in the budget, it has been decided to commence the roll-out of a universal GP service free at point of use by ensuring that all children aged five years and under will have access to a GP service without fees. New additional funding of €37 million has been ring-fenced by the Government to fund this new initiative so that it does not draw on resources for the medical card scheme. Including the 93% coverage of the over-70s population, this additional coverage of those under six will mean that almost half of the population will have access to GP services without fees. This Government is committed to achieving the goal of a universal GP service before the spring of 2016.

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

I welcome the Minister of State, Deputy Alex White, and thank him for coming to the House. I meant no disrespect to him but I missed part of his address as I got my times mixed up. Nonetheless, I am confident I know what was in his address.

No disrespect was taken.

Needless to say, we will vehemently oppose this Bill on the basis that we should always be able to extend ourselves for the relative security and protection of the vulnerable and the elderly. While I know the Minister of State was a very welcome and excellent colleague in this House at the time, it is impossible to consider this legislation without assessing the response of the Minister, Deputy Reilly, and others who are in government now in terms of their narrative at the time that a much more generous eligibility criteria was being considered. I recall people in the Opposition almost fighting with one another to get up on the truck on Kildare Street outside Leinster House to speak to the very considerable number of elderly people who had gathered in protest at what was a wrong initiative by the then Government in terms of adjusting the eligibility criteria. There was a row-back from that position, as we know, to an eligibility limit of some €1,400 for a couple and half of that for an individual.

The Minister, Deputy Reilly, was the player with the starring role among the Opposition at that time. He said:

...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. This decision is morally wrong and the people of the country know it.

At that time, 2008, the now Tánaiste, Deputy Gilmore, spoke on the lorry outside about how people had protested for civil liberties in the 1960s, for tax equalisation in the 1980s and were now rightly protesting for fair eligibility for medical cards. The current Taoiseach, Deputy Enda Kenny, said, "Shame on you. Shame on you. Shame on you", and that was in regard to a more generous eligibility criteria of some €1,400 at the time.

On top the 20,000 cards that were taken away over the course of this year due to the budgets, and even though the Taoiseach has lately said no more than 3% would be affected by any change to the criteria, which would be only some 11,000 cards in total, the reality is that in the region of 35,000 people over the age of 70 are set to lose their cards. One wonders what has changed. In the House earlier we were celebrating the relatively welcome development of Forbes highlighting Ireland as one of the best places in the world to do business, according to its metrics and tables, and both sides of the House acknowledged the encouraging signs in terms of employment and also income tax returns, of which I spoke earlier today. The net gain to Government of this measure is some €25 million in savings, although we are €520 million ahead of schedule up to November, at a time when no more than one sixth of our total tax take is catered for. Despite these surpluses, I acknowledge we are coming from a very low base and that there is debt we would like to eat into, which we will be able to do next week with the benefit of Bank of Ireland giving us back €2 billion. Surely, however, when there is some leeway, figures can be adjusted and we can look at this and decide that, while we know we must make savings, this will bite hard, so let us look at not doing it. Let us say: "We will be able to take this €25 million from another area because the relative health and protection of those over 70 is extremely important to us."

As I said, in 2008 the then Opposition participated in the anger and the narrative of the justifiable protests of the day, at a time when the limit was €1,400 per week. Now, it is down to €900 and, in effect, we are going to crystallise a discriminatory measure in this Bill whereas, historically, the practice has always been that if it was €700 for an individual, it was twice that for a couple, which is €1,400. Instead, this time it will be €500 for an individual but €900 for a couple, thus discriminating against those people who happen to be lucky enough to have a loving relationship in a marriage for a lifetime. One wonders why this is the case.

I appreciate this is all about the fight for resources. We had a good debate in the House last night on mental health, always the poor relation, I would argue, in terms of the cuts, in that when it comes to the budget, that is money to be ring-fenced until such time as it is needed, but we then pull it out again and it is no longer ring-fenced. When it comes to the less well-off, the over-70s and children, we really ought to be prepared to push that boat out a little further, particularly given the information coming our way in the last week is encouraging in terms of additional resources becoming available.

There is an element of gimmickry on the issue of the under-fives. I have children under five who will get free GP care, and, of course, I will take it. However, should I be eligible for it? No, I probably should not as I am on €65,000 a year. A very small percentage of the public service is on that kind of wage, and some are on significantly more than that, not least the Minister of State, officials and so on. This is the case throughout the country. We have often mentioned known wealthy people and, in jest, said we do not want to be providing free GP care to people who have many millions, and so on. I am not sure we have the element of joined-up thinking and the whole-health service approach for which the Minister of State would probably yearn, although I realise there are a lot of difficulties within that.

I believe this measure is wrong. If we read back and assess the responses at the time of the then Opposition, I believe what they said was justified at that time and is no less justified today, except from a financial position. The Minister of State will recall that at the time, although I was finance spokesman in this House, I would not hold back when it came to criticising my own Government, particularly on health matters. We have a different set of financial circumstances now that are arguably much stronger than they were at the time. If one wanted to be party political about it, those opposite will say it is all because of their great work over the past two and a half years, which would be a bit naive on the basis that the late Brian Lenihan took major decisions at the time.

It is Second Stage. This is something we do not have to do. The figures ought to allow, in a discussion with the Ministers, Deputies Noonan and Howlin, that the Government should not have to do this, in particular given the more positive situation. This is notwithstanding the unpublished Labour Party policy of looking at those earning an income of over €100,000, who were conditioned over the last two budgets to give a little bit more but were not touched. Those people could still give a little more. For the relative health and security of our elderly and our children, that could and should be done.

I welcome the Minister of State to the House. This Bill amends the qualifying criteria for medical cards for the over 70s, but it needs to be put in perspective, in that, when the scheme was introduced, there were free medical cards for everyone aged over 70 years without a consideration of the cost. Nursing home care was one such cost. As far back as 1976, the Maud McInerney High Court case defined nursing home care as falling under the qualifying criteria for medical cards. Therefore, if one had a medical card, one was entitled to free nursing home care. As a result, the introduction of the medical card for all over 70s created problems, in that it subsequently led to the Department needing to pay out nearly €500 million in the refund of nursing home charges.

My colleague on the other side of the House, Senator MacSharry, has referred to the hit and miss approach to adjusting policy. We want to introduce a planned policy over a number of years. We are putting in place a regulation covering the qualifying criteria for people with incomes. It is not about removing medical cards. People have an entitlement to a GP card.

Another issue that has been left out of this debate is the cost of medication. A major effort has been made in recent months to reduce the cost of generic medicines. The situation that used to obtain showed the unplanned approach that had been adopted in the preceding ten years. Some 18% of our pharmaceuticals are generic, whereas the figure in other European countries is as high as 70%. The cost of medicines has been unrestricted for a long time. If someone has a GP-only card, the maximum price that he or she must pay is €144 per month, after which he or she is entitled to a refund. It is important that we keep this in mind. It is not the case that every item a person gets for free will suddenly start costing the full amount.

Since the Government entered into office, 254,000 additional medical cards have been issued, increasing from 1.7 million, including GP-only cards, to 2.001 million in June. This figure has changed somewhat in the past two or three months, but it is a significant number, representing 43% of the population.

Some 35,000 people will be affected, but 49% of the population will have a medical card or a GP-only card after we introduce the GP-only card for children aged under six years. This is a significant step on the part of the State. Despite the economic pressures, we can look after people who no longer have the level of income that they previously enjoyed. We have been decisive in giving this level of support in recent years. We have specifically set aside €37 million to budget for the cards for children aged under six years.

The Department of Health has taken all of the right steps in the past two years. One cannot change budgetary management overnight, but significant efforts have been made, particularly in the past 12 months. In an unplanned way, we allowed the cost of drugs to increase from more than €570 million in 2000 to more than €2 billion a year ago. Now, a serious plan is in place to reduce the cost of medication and, therefore, the cost of health care for the taxpayer, allowing us to increase the level of services provided.

The Bill is a step in the right direction and ensures that we take a planned, rather than piecemeal, approach. A mistake was made between 2000 and 2010, in that many policy changes did not form part of a planned approach. We have set out our health care plan for the next five to ten years. It is a question of achieving changes.

A point I highlighted at a meeting of the health committee has since taken on a life of its own. I raised it on 17 October, having submitted a question in September. It concerns the budget we are paying non-HSE and non-departmental organisations, which amounts to €3.27 billion or 25% of the overall budget. This expenditure has not been subjected to significant scrutiny during the past ten or 15 years. It is as if there were no limits. Now, the Department is examining it carefully. Last week, I tabled an Adjournment matter at which the Department again confirmed that it had written to the section 39 organisations asking them to comply with pay policy so that the same levels of pay might apply in those organisations as apply to equivalent posts in the HSE. This welcome development shows that the Minister of State, Deputy White, his colleagues, the Minister of State, Deputy Kathleen Lynch, and the Minister, Deputy Reilly, and departmental officials are dealing with the health budget in a more planned and structured way. As a result, there will be a benefit for the taxpayer and people who are entitled to supports. We will also be able to expand those supports.

I thank the Minister of State for attending, for introducing this legislation and for ensuring through it that the most vulnerable, for example, people with low levels of income, are looked after.

I welcome the Minister of State. I do not envy him his job of balancing the books, as it is never easy, but it must be done. The State is still spending more than it is earning. We must find a way. Some of the figures provided by the Minister of State mean that we will need to make some difficult decisions. It was easy to be generous during the good times.

I will not attempt to cover all of the figures supplied, as there are too many. I will touch on a particular one, that of the General Medical Services, GMS, scheme, which costs €2 billion per year. From where will we get this money? We must make adjustments. More than 40% of people currently hold medical cards, compared with 27% only six years ago. This shows how we can get into habits and assume that they can continue. We must balance the books. I will not spend more time on this point.

In general terms, I agree with the principle that those who have more money should pay more, but I get exasperated when the State claims it cannot, for example, means test child benefit. I do not understand it. It is absurd that wealthy people receive such benefits, resulting in the Government needing to find savings elsewhere. Senator MacSharry discussed this issue easily, hopefully regarding himself.

While I believe that the measures in the Bill are a relatively small step in the right direction, we must ensure fairness. In this respect, I would like an answer to a question that I raised previously and that Senator MacSharry has asked today. Why is the allowance for a couple not exactly double that for a single person?

I do not understand that. It is unlikely people over 70 years of age are living in sin. Perhaps they are. This provision may encourage people to live in sin rather than get married.

Under this Bill, as passed in the Dáil, the income limit for a medical card for a person aged over 70 will decrease from €600 to €500 per week and for a couple from €1,200 to €900 per week. If the income limit for a single person is €500, why is it not €1,000 for a couple? I do not understand that and would welcome an explanation in this regard. It is an issue that has been raised by many people. Is there a policy in relation to this or from where is this coming?

In balancing the books many uncomfortable decisions have to be made. The Minister is not to be envied. We are going in the right direction. These types of decisions must be made. While I support the Bill, I would welcome an explanation in relation to the query I have just raised.

I welcome the Minister of State to the House to discuss this technical amendment to the Health Act 2008. Even though it is only a technical amendment it is a fairly important one, not least in terms of the potential it offers to the Opposition to make mischief and scaremonger the very people they purport to protect. The temptation also exists for the Opposition to conflate, as Senator MacSharry has already done, this technical amendment with many other things that are happening in terms of reform of the health services, including free GP care for children under six and the many other concerns which people have about health service reductions.

As stated by the Minister of State, a safe, quality health service despite reductions in spending must be to the fore of everybody's mind. As identified by the Minister of State, the cost of the general medical services scheme is in excess of €2 billion per annum, which is an incredible amount of money. This €2 billion combined with the €3.8 billion, which as stated by Senator Burke is provided to the section 38 agencies, amounts to more than half the entire spend of the health service. This indicates the level and scale of the problem facing the Minister. If we cannot balance the books, savings have to be made. Regardless of from where savings in the bigger spending Departments are sought by Government, there will be pain involved.

Some 1.86 million people are now entitled to a medical card. This means there has been a 60% increase in this regard in recent years. As stated by Senator Quinn, 43% of the population of this country meet the medical card eligibility criterion. In 2008, the qualifying eligibility for a medical card was greatly expanded. Some people would say that the extension of eligibility for a medical card to all people over 70 years of age may not have been based on medical evidence. Some people would go as far as saying that there were perhaps other considerations foremost in the then Minister's mind that again were not based on medical evidence. We could seek evidence as to whether there is any support for that contention. I believe there might well be. The then Minister massively under-calculated the number of people who would be eligible, resulting in an immensely unplanned spend in this area. As stated by Senator Burke, planning and certainty are key in the delivery of any services. He also referred to other initiatives in respect of which a previous Minister did no planning, including the nursing home refunds scheme. When asked about this issue in committee, the then Minister put the blame on his officials. Current officials need have no fear in this regard as this Government will happily accept responsibility in respect of any planning undertaken by it, including any negativity arising in that regard.

Approximately 7% of those who are better off in Irish society will be affected by the change in the eligibility criterion for medical cards. Under this Bill, to be ineligible for a medical card a person must be in receipt of a pension of approximately €24,000. The threshold in this regard for a couple is €47,000. I understand that in this regard 35,000 people will be affected, which is a substantial amount of people. However, fairness being the underpinning value of everything this Government intends to do, it is fair, if unpalatable, to ask the better off in our society to contribute a little more. This has been said by Members on all sides. To say that the Government is reducing eligibility in this area is true. To say that it dislikes doing so is also true and to say that it is necessary is also true.

I look forward to hearing the Minister of State's Second Stage response and to engaging further with him on the Bill on Committee Stage.

Under this Bill, more people over 70 will lose their medical cards and fewer will qualify when they reach the age of 70. Prior to 2008, people over 70 received a medical card without a means test. When the Fianna Fáil-led Government decided to end that entitlement, the current Minister for Health, Deputy Reilly, then Fine Gael health spokesperson, described it as a "vicious attack" and a "savage assault on the elderly". We then had the Fianna-Fáil led Government's climbdown in the face of mass protest. The 2008 legislation set the income limit for over-70s medical card qualification at €700 per week for a single person and €1,400 for a couple. In response to that proposal then Deputy Reilly said it was a "desperate climbdown" and that "their tinkering with income limits is nowhere near good enough". Since then, Deputy Reilly has become Minister for Health. Has the hardship for older citizens lessened since that day in 2011 when he received his ministerial seal of office? It most definitely has not. Is the removal of medical cards any less an attack on them now than it was in 2008? It most definitely is not. The only difference is that Deputy Reilly is now the Minister for Health and different standards must apply according to him and the Government.

Under budget 2013, the income limit for over-70s medical card qualification was decreased from €700 per week to €600 for a single person and from €1,400 per week to €1,200 for a couple. It seems that tinkering with income limits is good enough when it is this Government that is doing the tinkering. This Bill proposes a further reduction in the income limits to €500 per week for a single person and €900 per week for a couple. The fear expressed by elderly people that once a means test was introduced and the income limits had been set very high, it would be a slippery slope to more elderly people losing their cards was real. It is expected that some 35,000 older citizens will lose their medical cards as a result of this change. As stated by Age Action Ireland:

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.

Prescription charges for all medical card holders have been increased to five times the original charge per item introduced by former Minister for Health and Children, Mary Harney, a measure Fine Gael and the Labour Party vehemently opposed in the Houses of the Oireachtas. This increase hits older people badly. The changes introduced in this Bill, taken together with the abolition of the telephone allowance and the prescription charges increase, make budget 2014 a particularly nasty one for older people. I remind the Government that the Minister, Deputy Reilly, championed Fine Gael's fair care health policy with its promise of universal primary care. Fine Gael and the Labour Party received record mandates in the general election of 2011, with manifestos that promised greatly extended and then universal entitlement to free primary care. The programme for Government states that universal primary care will do away with fees for GP care and will be introduced within this Government's term of office. The Minister, Deputy Reilly, promised that the first phase of this, namely, extension of free primary care to claimants of free drugs under the long-term illness scheme would be in place in summer 2012 but it was not. There were supposed to be drafting difficulties because of the change from entitlement based on income to entitlement based on forms of illness. In the autumn of last year we were told by the Minister that it was still on track and a Bill in this regard would be introduced.

When the Health (Alteration of Criteria for Eligibility) (No. 1) Bill, came before us last March, there was no Bill to extend free primary care in any way. Instead, the Minister, Deputy Reilly, had come full circle, from IMO opponent of over-70s universality to IMO beneficiary of it, to vociferous Dáil opponent of change to it and to now imposing a further restriction to the scheme, leading to thousands of older people losing their medical cards.

The Bill further restricts access and cuts 35,000 medical cards. When they were in opposition, both Fine Gael and the Labour Party pointed out that restricting access to primary care was penny wise and pound foolish because older people would suffer poorer health outcomes and require more hospital visits, inpatient care and residential nursing home care. Now, they are further restricting medical card access as a so-called savings measure that will adversely affect the health of older citizens. It is another smooth transition from Fianna Fáil to Fine Gael and the Labour Party. There is not a hair's breadth between them. One simply cannot see the difference. We are told the difference is that the Government has provided for free universal GP care for children aged five years and under. I welcome that measure, as far as it goes, but if it is not part of a clear programme of extension of free GP care to all, with a limited timetable, it might actually undermine the principle of universality. If the Government was genuinely pursuing a policy of universality and a single tier health service with access based on medical need alone, it would have Sinn Féin's support. However, that is not the case. There might be members of the Labour Party who delude themselves into believing they are pursuing such a path, but it is far from the position of Fine Gael in the Government.

A total of €37 million is to be spent on GP cards for children aged five years and under, but €149 million is to be taken from the medical card budget. It is robbing Peter to pay Paul. We are giving some people a medical card, but we are taking it away from older people and have seen what is happening with discretionary medical cards. That is the reality and no amount of spin on the part of the Government will counter it. The reason more people qualify for medical cards is there are more people unemployed and in low income jobs than has been the case for a number of years. That is the reality and why more people need and should have medical cards.

The last speaker said there was no difference between Fianna Fáil and Fine Gael. There is a major difference. The Government has a plan for how it will proceed in the health service and the legislation we are discussing today and the changes introduced in budget 2014 are part of the Government's movement towards the goal of introducing a universal GP service for all before the spring of 2016. That is a major difference. There is a plan, towards which we are working as a goal. Nonetheless, nobody wishes to see reductions, particularly in eligibility for medical cards for people over 70 years of age. However, one point must be made repeatedly. I listened to a vox pop conducted during a demonstration outside Leinster House in opposition to the proposals introduced in budget 2014. One man said he was there to object because his medical card was being taken from him and VHI was being taxed. After this measure is implemented, only 7% of people over 70 years of age will not have a medical card or a GP card.

That is not what Taoiseach and the Tánaiste said during the protests in 2008. We all remember what they said then.

The person who was speaking obviously had VHI or private health insurance.

The value of a GP card should not be underestimated. It has been glossed over by the Opposition in this debate, but it is a very important support for the elderly. I have spoken to many people who depend on their GP for advice and support when they are worried about an aspect of their health. Free GP services which are part of primary care services ensure there will be no barriers to accessing care. They will ensure early detection of health issues and prevent them from becoming more complex and expensive to deal with and, more importantly, becoming a worry for the individual in terms of consultant visits and hospital care if medical conditions are allowed to get out of hand. The provision of free GP care is very important from that point of view and the matter should not be glossed over or dismissed as the Government ignoring the elderly because it is not. It is also making provision for children under six years of age. The introduction of these measures in the recent budget will ensure 93% of the population aged over 70 years will have cover. Combined with the coverage of children aged under six years, this means that half of the population will have access to GP services without fees. It is a significant improvement and I commend the Minister for it. He is very committed to the provision of primary care, which is essential in preventing a medical condition from getting out of control. Free GP care provision will be very important in that context.

It is important to mention that this country looks after and respects its elderly. The income limits for people over 70 years of age are considerably greater than those for somebody aged 65. There are also the taxation measures for people over 70 years. The treatment of income from capital in terms of savings or investments is exempt where the value of the capital does not exceed €36,000 for an individual or €72,000 for a couple. There is also free travel, as well as a free television licence. I acknowledge that the telephone allowance was removed in the budget, but that the Minister for the Environment, Community and Local Government has increased funding for alarm systems is welcome. These measures are in recognition of the fact that elderly people living alone must be supported in their communities.

While nobody likes removing any provision, the point must repeatedly be made that only 7% of people aged over 70 years, a very small number, will not have access to a medical card or free GP care after the enactment of this legislation. I wish the Minister well in his work in ensuring that by 2016 we will have access to the best primary health care facilities in the world.

I thank Senators for their contributions. Very interesting points were raised in the course of the debate.

I will start by referring to two points made by Senator Deirdre Clune. On the extent to which the Government has acted in a proportionate way in its actions in respect of eligibility for people over 70 years, the Senator brought a measure of balance to the debate by pointing out, as I have many times, that 93% of all persons over the age of 70 years will continue to have access to their GPs without fees. A somewhat lower figure, 85%, have access to a full medical card. If Senators pass this measure and it is enacted, 85% of all citizens over 70 years of age will still have a full medical card, while a further 8% will have a GP card. That gives a total of 93% who will have access without fees to their GPs.

The second point made by the Senator was on the importance of access to a GP without the barrier of fees. The bedrock of a universal primary care system is that we remove the barrier of fees for attending one's doctor. Senator David Cullinane queried how serious the Government and I were in this respect. We are very serious. It is not just a gimmick, as Senator Marc MacSharry suggested; it is not just something that is desirable in its own right, as it is, it is also a necessity. No country in the world and no taxation or health insurance system will be able to fund and sustain a modern health system unless it adjusts towards primary care provision. That is a fact. Let us consider the experiences of any country in the provision of health care and the challenge presented in dealing with chronic illnesses. We live in a completely different world from the world of 20 or 30 years ago in terms of what we must do in the health service. There are massive challenges presented by diabetes, cardiovascular illnesses and so forth which demand that we refocus our attention on preventive strategies. They can only be carried out in primary care settings.

We must gradually shift resources out of the acute services in order to ensure that we address the challenges of the present and the future in a proper way.

The primary care strategy of 2001 that Senator MacSharry's colleague, Deputy Micheál Martin, introduced, was a very good document. It set out a lot of the challenges that the then Government saw. The challenges still exist. We have made progress towards addressing them but not anything like enough progress. We have experienced times of serious financial constraint and this means that we have been limited in what we can do about them. I do not accept Senator Cullinane's suggestion that we take with one hand and give with the other. This is a time when we must make savings and balance the books. However, we must also have a vision for the future and put aside some money to invest in the future for the health of all our citizens. We can only do so by adjusting towards primary care. In my respectful view, the system will literally not sustain itself unless we do so. It is a necessity. I do not stand here as a politician just expressing a whim when I say that we must remove the barrier of fees charged when one attends a GP. There is a lot of evidence that proves that even relatively well off people will not go to their doctor because fees ranging between €50, €60 or whatever act as a disincentive. We must remove the commercial relationship between the citizen or patient and his or her doctor. It is a progressive move that we must achieve.

First, a good place to start would be extending free GP cover to those under 6 years of age. Senator Cullinane will recall that the programme for Government outlined a route that would commence with long-term illness people and then move to high tech drugs. Last May the Taoiseach made a very clear statement that we were looking at a better and faster way to achieve that goal.

We have dealt with the matter in the Chamber before. One could have regulations instead of having complex legislation that would set out the base upon which one would give a GP card to people who have various illnesses or conditions, and all of the attendant complications and cumbersome legislation and regulations that would apply. One could have regulations that stipulated that the diagnostic basis of asthma and the different forms of cancer that qualify for a medical card. On examination these matters are far more complicated than initially thought. It is fair to admit that they are far more complicated than they looked to the people who, with the best will in the world, compiled the programme for Government. We have examined a different route. The under-6s provision is an interim measure that has been criticised by Senator MacSharry and others as a gimmick. It is not a gimmick because it cannot be one. It must be part of the implementation of full access for the entire population to GP services without the barrier of fees. I ask colleagues to reconsider. There is no other area of public policy where it is more urgent that we work together than on the future configuration of the health services and their funding. Universal primary care is an absolutely essential in order for us to achieve that goal.

Senator MacSharry criticised the measure but he did not attack it. He raised the issue about the wisdom of universality and gave himself as an example as someone who has young children and is perhaps better off. People on relatively low incomes cannot qualify for a medical card. Oddly enough, there are people on low to middle incomes who would not pass the incomes limits set for a medical card and Senators will know that from their work as politicians. Therefore, it is far from a case of us satisfying millionaires or people who are well off by providing a medical card for children aged under 6. The measure will help families on low and middle incomes but some people who are millionaires or very wealthy will also benefit.

That leads me back to the tried and tested debate on universality. I ask Senator MacSharry and others present to consider the following. We never argue about all children having access to primary education. We do not means test access to primary education because we regard it as an absolute bedrock entitlement of every child, irrespective of the income of parents. Immunisation is another example. There is a range of fundamental rights and entitlements for all children in the State and health care ought to be one of them. What else would be on the list if health care and primary health care were not?

In terms of equity and ensuring equity, there are many other instruments that we can address in that regard. The taxation system is an obvious one. Senator MacSharry asked whether very wealthy people are subjected to enough tax but I did notice such a proposal in Fianna Fáil's manifesto for the last election.

It was and it was in the Sinn Féin one too.

Do not mind Sinn Féin, Senator.

From what we have heard of the Labour Party one it showed Fine Gael did not get the provision over the line.

That is Fianna Fáil passing over things.

Fianna Fáil is quoting Sinn Féin.

Fianna Fáil did not favour it before the election but now throws it at us for not doing so.

In its wisdom, the Government did not make me the Minister for Finance.

Fianna Fáil is using it as a stick to beat us with but it did not advocate the provision before.

The taxation system is an important instrument to achieve equity in society and the economy rather than means testing something as vital as health care. The health care system is bedevilled by the means-test culture. I say that personally but hopefully not just on my own behalf. We want to get away from means testing for access to basic health care.

Having universal access to a GP without fees is the best way of doing so. I am grateful for Sinn Féin's qualified support of the measure but I do not quite understand Fianna Fáil's position. I have no doubt that we will have further opportunities to discuss the matter.

We will see if Fianna Fáil still opposes such a progressive measure when it is rolled out in the spring of next year.

I thank the Senators for their contributions. Senator Colm Burke rightly praised the Government's planned approach to reforms. As I have said and shall repeat, my vision of universal primary care is one of full universal access to GP care without fees. It should be the norm for the entire population. However, there will still be a proportion of the population who will need funding for their drugs, and in many cases full funding for their drugs. I think that there will still be a necessity to maintain the drugs payment scheme.

As Senator Colm Burke pointed out, there is a limit of €144 per month. I shall engage in the following debate without signalling a policy intention. There may be a case for an interim entitlement that ranges somewhere between €144 and having completely free drugs. There might be a better graduation in terms of what we can do for people. That is something that we would need to examine in the future and I look forward to debating the matter here.

Senator Quinn also raised the issue of universal access. I have addressed the matter but I am sure that I can return to it again. He raised the issue of differential treatment of a couple and a single person and I can explain the rationale for doing so. The living costs of an individual living alone are more than half the living costs of a couple living together. It is the Government's view, and appears to be the case, that expenditure does not necessarily diminish relative to the number of people in the household. There are economies of scale and I hope that I have used the term correctly. In that context, the over-70s income limit for a single person has been reduced proportionately less than the income limit for a couple.

The differential concept is not new or an isolated example but is evident in other areas of public policy. For example, the State pension 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 live alone; differential income limits apply for medical cards for persons under 70 years between individuals and couples; and in the assessment for supplementary welfare allowance, a differential applies whereby the rate for a dependent qualified adult is not half the personal rate of the applicant. Finally, the Insolvency Service of Ireland guidelines used various scenarios but a significant extra sum was not allowed per month, after tax and PRSI, for a couple compared with a single person. This differential treatment of a couple and a single person is not unique.

Senator Gilroy made some interesting points and observations.

I would certainly accept the point that there is no cut in an area like health, or virtually none of which I can think, where one could say there was no problem associated with it or there was not some adverse impact or pain, which was the word used. The objective of a progressive and a caring Government is to ensure we minimise that adverse impact and do what we need to do in as fair a manner as is at all possible.

I think Senator Cullinane made the point that we are introducing the under six measure but are changing the eligibility in regard to over 70s. If the Seanad agrees to this measure, no one will lose GP access because anyone who loses their full medical card as a consequence of this measure will have a GP card - without quibble. There is no question of a new application regime or otherwise, so it is not inconsistent with universal access to GP care. If we were taking anybody out of free GP access, a case could be made that it was inconsistent. Giving it to some and taking it from others would be inconsistent and we would stand to be criticised on that but that is not what we are doing. We are not taking free GP access from a single citizen as a consequence of the measure we propose to the Seanad.

Question put:
The Seanad divided: Tá, 24; Níl, 10.

  • Bacik, Ivana.
  • Barrett, Sean D.
  • Brennan, Terry.
  • Burke, Colm.
  • Clune, Deirdre.
  • Coghlan, Eamonn.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Donnell, Marie-Louise.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Quinn, Feargal.
  • Sheahan, Tom.
  • van Turnhout, Jillian.
  • Whelan, John.


  • Byrne, Thomas.
  • Cullinane, David.
  • Heffernan, James.
  • Leyden, Terry.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • O'Brien, Darragh.
  • Ó Clochartaigh, Trevor.
  • Ó Domhnaill, Brian.
  • Power, Averil.
Tellers: Tá, Senators Aideen Hayden and Michael Mullins; Níl, Senators Thomas Byrne and Marc MacSharry.
Question declared carried.

When is it proposed to take Committee Stage?

Committee Stage ordered for Tuesday, 10 December 2013.

When is it proposed to sit again?

Next Tuesday at 2.30 p.m.