We will come to the practice. Neither has there been a change in the rules of awarding medical cards on discretionary grounds. The medical card scheme continues to operate such that those who suffer undue financial hardship, as assessed according to the published HSE guidelines, in the arranging of general practitioner services are awarded a medical card.
While the number of medical cards issued on discretionary grounds has fallen in recent years, this is not as a result of a change in policy or a deliberate targeting of discretionary cards. Rather, it is attributable in the main to the fact that many people - I can give the figures again - who previously were marginally over the qualifying means thresholds have subsequently been granted medical cards because they now fall under those means thresholds. Of the discretionary medical cards in circulation in 2011, approximately 6% have subsequently been refused a discretionary medical card on review. While the number in this regard may be small, I in no way underestimate the difficulties caused for those who are considered or found to be ineligible.
However, the legislation is clear that qualification for a medical card is means-tested. As a result, some people have been found to be ineligible because their net income is in excess of the means thresholds, sometimes by hundreds of euro per week. As I outlined previously, the HSE is currently examining how individuals who are not entitled to a medical card could still receive services that meet their needs. The issue is being addressed in a manner that includes all of the services and supports provided by the HSE with as much flexibility as is available and at a local level.
All medical card and GP visit card holders are subject to a periodic review of eligibility to determine whether they remain eligible. The change in the number of existing cards will be dependent on the extent of ineligibility detected. Given that medical card eligibility is assessed on an individual basis it is difficult to estimate the number of medical cards that may be awarded on a discretionary basis.
It is important to note that where a medical card is withdrawn, irrespective of its having been awarded based solely on means or where the HSE has exercised discretion, it is not withdrawn due to the cost implications for the HSE. In accordance with the Health Acts, a medical card can only be withdrawn due to eligibility not having been established.
The medical card system is founded on the test of undue financial hardship in arranging GP services. Assessment for a medical card is determined primarily by reference to the means, including the income and reasonable expenditure, of the applicant and his or her partner and dependants. In the case of a child, the parents' income and reasonable expenditure is assessed. Under the legislation there is no automatic entitlement to a medical card, nor has there ever been, for a person with a particular disease or illness.
Determination of eligibility for a medical card is the responsibility of the HSE. I will outline the matter of practice that I was asked to address. The HSE has produced national assessment guidelines to provide a clear framework to assist in the making of reasonable, consistent and equitable decisions. The guidelines do not provide for expenditure associated with property taxes or water charges to be included in the determination of means of the applicant. On the issue of water charges, the Department of Health has not been involved in discussions on the exempting or capping of water charges for certain medical conditions but it is available to do so.
As I remarked earlier, one of the consequences of the transition to a nationally consistent system of assessment has been difficulty at renewal stage for higher income households or persons on relatively higher income, even where an illness or disability is involved. On the initiative of the Minister for Health, the HSE established a panel of community medical officers to assist in the processing of applications for medical cards where the income guidelines were exceeded but where there are difficult personal circumstances, such as an illness or physical disability that may have an impact on the financial situation of the applicant. The medical officers review evidence of necessary medical expenses provided by the applicant. As appropriate, he or she liaises with general practitioners, hospital consultants and other health professionals such that the costs relating to the health circumstances of the applicant can be taken fully into account.
At the request of the Minister, Deputy Reilly, the HSE is currently examining how individuals who are not entitled to a medical card could still receive services to meet their needs. As I said earlier, this examination relates to all of the services and supports provided by the HSE with as much flexibility as is available and at a local level. Additional information will be provided and local information points will be established at major health centres throughout the country, where members of the public can obtain comprehensive information and support in accessing their full range of supports from the health services. Appropriate notice is also being considered as part of this review for existing medical card holders who may no longer be eligible on renewal but where serious medical conditions or profound disability continues to exist in the household. The objective is to maximise the supports available for patients and families.
The Government is fully aware of the difficulties caused for those who are considered ineligible. Indeed, one of the key goals of the reform of the health system is to ensure that people receive health care according to their particular needs rather than based on their income. Historically, eligibility for health services in Ireland has been based on a person's means. This, I believe, is an anachronistic and inappropriate basis for a health system and is far from any comparable modern health system of any European country. It underpins the importance of moving towards a health system based on universality of access. These major reforms take time and, in the meantime, I look forward to seeing proposals from the HSE on how individuals who are not entitled to a medical card could still receive care that meets their needs under the existing health legislation.