Wednesday, 10 December 2008
Dáil Eireann Debate
Minister for Health and Children (Deputy Mary Harney): The Health Bill 2008 gives effect to recent Government decisions to end the automatic entitlement to a medical card, irrespective of income, for people aged 70 years and over and to introduce new arrangements in order that the vast majority of people aged 70 years and over will continue to have medical cards under a new income threshold.
With the enactment of this Bill, people aged 70 years and over will have three gateways to a medical card. First, under the new gross income limits, we expect 95% will qualify because their income will be below the new limits of €700 a week for a single person or €1,400 for a couple. Second, people whose gross income is above the limits may still apply for a medical card using the standard net income means test which applies for people aged under 70 years. This takes account of personal circumstances, such as high outgoings on nursing home fees. Third, a person may still apply for and be granted a medical card if his or her health circumstances cause undue hardship, under the discretionary medical card arrangements. Many people who have terminal illnesses, for example, are granted medical cards even if they do not qualify under the means test.
For those who are now aged 70 years or over — or become so by the end of this month — there will be no new means test. For those who turn 70 years in the new year, there will be a much simplified means test, designed to show that their gross income is below the new limits. These new arrangements will improve the sustainability of financing of medical card services for older people and allow resources to be targeted to those most in need. In particular, they enable the ending of the specially high capitation fee for general practitioners which has been paid since 2001 only in respect of over 70 year olds who received a medical card by virtue of age rather than means. This payment had the distinction of being discriminatory, inequitable and financially unsustainable. It was paid in respect of about 38% of people aged 70 and over. A wide range of people, including general practitioners, is pleased that the perverse incentive that this special fee created between different general practices is being ended. I welcome again the recommendation of Mr. Eddie Sullivan of a single fee capitation level of €290, which we intend to implement from 1 January next.
Under existing legislation, the objective of the general medical services scheme is to ensure the medical card benefit is available to those who are unable, without undue hardship, to meet the cost of health services for themselves and their dependants. People aged 70 years and over are more likely to require regular access to health services and it is appropriate that additional support is put in place to enable their access to medical care. At the same time, it is consistent with the general approach of the GMS for many years and the need to provide for financially sustainable schemes, that the medical card should be provided to all but the top 5% of income earners among the over 70s. There are and will continue to be pressing calls on scarce resources to meet the needs of many people across the whole range of health services. Fundamentally, it is better that we devote taxpayers’ funds to meet those needs rather than pay for access to medical services for those who can, in any event, have full access to general practitioner services using their own resources.
Fortunately, people in Ireland are living longer and healthier lives. This is due in no small part to better health services and the higher living standards as a result of economic growth. We also have the youngest population in Europe, with only about 11% of people aged over 65 years. This will change in the years ahead as our population ages and lives longer. We we should welcome and prudently plan for the development in every respect, including Exchequer commitments.
The number of people over 70 years is projected to increase to 363,000 by 2011, 433,000 by 2016 and to 535,000 by 2021. We need to plan for and provide many health services for the people now aged 55 years and over who will form the over 70 age group at that time and use public resources in the most effective and fairest way to provide these services. In that context, the continuation of the automatic medical card and the specially high capitation fee paid for it does not represent prudent or fair financial planning. Resources should be used for those with the greatest medical and financial need. While some people counter this basic principle with a call for universalism in all services, it is highly relevant that our primary care services, in particular, GP practices, provide the same service to all, irrespective of the basis of payment. That is a universal service. A quality service that is accessible by all, with different rates of contribution or payment, based on means, is one that is equitable and fair.
I now propose to briefly outline the main provisions of the Bill. Section 3 provides for the replacement of section 45(5A) of the Health Act 1970 which provided, since 2001, for an automatic entitlement to a medical card for all persons aged 70 years and over who are ordinarily resident in the State, irrespective of their means. The old section 45(5A) is replaced by this new section 45(5A) which provides that those people who are aged 70 years or over before 1 January 2009 and who had full eligibility on age grounds will continue to have full eligibility provided their gross income from all sources does not exceed the specified limits. These limits, which are set out in section 45A, are €700 per week gross in the case of a single person, excluding any income from savings or similar investments whose principal value is €36,000 or less, and €1,400 per week gross in the case of a couple, excluding any income from savings or similar investments whose principal value is €72,000 or less. A person who was automatically entitled to a medical card, and therefore had full eligibility by virtue of the old subsection 45(5A), will continue to have full eligibility until 2 March 2009. Consequently, all persons can continue to use their medical card as normal until 2 March 2009 even if their gross income exceeds the relevant income limits set out in this Bill.
Section 4 provides for the insertion of a new subsection, 45(A), in the 1970 Act dealing with the eligibility of persons aged 70 and over, and their dependants, for a medical card from 1 January, 2009. It provides that people reaching 70 on or after 1 January will have to make an application to the HSE and provided they meet the income and other criteria of age and ordinary residency, they will receive a medical card.
A simplified means test will be arranged to enable people to apply. They will receive confirmation from the HSE that they have full eligibility and will continue to have it so long as their gross income does not exceed the limit. This section also covers people who have already reached 70 prior to the 1 January 2009, but who, for a variety of reasons, may not have applied for a medical card under section 45(5A) of the Health Act 1970, which provided for automatic entitlement to a medical card for all persons aged 70 and over. This section provides that dependants of persons covered in this section and section 45(5A) will also have full eligibility.
The gross income limits which will apply under this Bill from 1 January 2009 for single persons are €700 per week, excluding income from savings or similar investments whose capital value does not exceed €36,000. For couples, the gross income limits are €1,400 per week for people who are married or living together as husband and wife, excluding income from savings or similar investments whose capital value does not exceed €72,000. The couple limit of €1,400 will also apply where the spouse or partner is under 70.
This section requires that I review the consumer price index annually on 1 September and provides that the gross income limits may be increased to reflect any increase in the index. In this Bill I am making provision for the exclusion of income, and interest earned thereon, arising from certain compensation awards payable by the State.
These include compensation awards to persons under the Hepatitis C Compensation Tribunal Acts 1997 to 2006, compensation awards by way of the Residential Institutions Redress Board, established under section 3 of the Residential Institutions Redress Act 2002, prescribed repayments made under section 8 of the Health Repayment Scheme Act 2006 made to a living relevant person, to the spouse or former spouse of a living or deceased relevant person, directly to a living child of a relevant person by virtue of section 9(8) of that Act and ex gratia awards approved by the Lourdes Hospital Redress Board under the terms of the Lourdes Hospital Redress Scheme 2007. It further provides that I may make regulations prescribing further payments made for similar purposes also to be excluded as income for the purposes of this Bill.
This section also gives effect to the Government’s commitment not to impute income from property. For the purposes of assessing gross income under this Bill, income will not be imputed from any property, whether it is a family home, a holiday home or any other property, unless it is rented, and only the net rental income, calculated as gross income less any costs necessarily associated with the rental of the property, will be included for this purpose.
Sections 5 and 6 are technical amendments which amend sections 47 and 47(A) respectively of the 1970 Act to provide for the new section 45(A) being inserted in the Act by this Bill. The amendment to section 47 provides that the appeals process available to persons under section 45 of the Act will also now apply to persons over 70 qualifying for a medical card under this Bill. The amendment to section 47(A) provides that guidelines on persons ordinarily resident in the State issued for the purposes of assisting the determination of an appeal under section 47 shall now also apply to persons qualifying for a medical card under this Bill.
Section 7 provides that people who are 70 years of age before 1 January and who hold a medical card on the basis of automatic eligibility under section 45(5A), prior to the enactment of this Bill, shall notify the HSE, no later than 2 March 2009, if they have concluded that their income exceeds the gross income limits. I want to ensure that the process of self-assessment required under this provision will be much simplified compared to that required under the existing hardship-based scheme. Consequently, I have asked the HSE to ensure that any assistance that a person may need in relation to self-assessment will be made available by the HSE on an administrative basis.
Subsection (b) amends section 49(2) of the 1970 Act such that the provisions applicable to a person who knowingly contravenes the requirement set out in subsection (1) to notify the HSE of any change in the circumstances that entitle him or her to a service provided by the HSE under the Health Acts shall also apply to persons qualifying for a medical card under this Bill.
The purpose of section 8 is to amend section 4 of the Health Contributions Act 1979 to provide an exemption from the health contribution for any person who is or reaches the age of 70 on or after 1 January 2009. The amendment will exempt everybody over 70 from paying the contribution regardless of whether they fall into the existing categories exempted under section 11 of the 1979 Act.
Sections 9 and 10 are technical amendments to the Social Welfare Consolidation Act 2005 so that the existing statutory provisions in relation to the sharing of information between public bodies, which already apply to section 45 of the 1970 Act, shall now also apply to section 45(A) of that Act as inserted by this Bill.
Section 11 is a technical amendment to ensure that the existing statutory provision in relation to the sharing of information between the Registrar of Births, Deaths and Marriages and the HSE, which already applies to section 45 of the 1970 Act, shall now also apply to section 45(A) of that Act as inserted by this Bill.
The Government has been concerned at all times in these new arrangements to ensure that a person aged 70 or over would not lose their medical card as an immediate consequence of the death of their spouse. We have explored all possible solutions in recent weeks within the boundaries of what was possible from a non-discrimination point of view as between widowed persons and single persons. I propose to introduce an amendment on Committee Stage to give effect to this objective.
This Bill is designed to give effect to the Government’s decision to replace the automatic entitlement to a medical card for persons aged 70 and over with a new arrangement based on gross income limits. Under the new arrangement, the limits are set at a sufficiently high rate to ensure that the majority of people aged 70 and over will continue to qualify for a medical card. I commend the Bill to the House and look forward to hearing the views of Deputies.
Deputy Mary Harney: I will ensure that the amendment is circulated later. It will ensure that for a period of three years a widow or widower will be assessed on their gross income and not changing circumstances, such as a pension being halved.
Deputy James Reilly: This Bill has been opposed by this side of the House and for good reason. I want to discuss some of the facts. There are 350,000 people over the age of 70 in Ireland and approximately 215,000, or 60%, have a medical card based on assessment. The other 40%, or 140,000, have a medical card on the basis of their age.
On 14 October the Minister announced that from 1 January the automatic entitlement would end and this cutback would save €100 million. We were very critical of this at the time because we felt this was taking the easy option and hitting the elderly rather than attempting to make savings through the renegotiation of the capitation rate offered to GPs, the prescribing of generic medicines and negotiations with pharmacists. A vote was forced on the issue. It is important to point out that many backbench TDs from the Government side spoke against this, but then voted for it. They certainly spoke out against it in their constituencies, but when it came to walking the walk, only Deputy Joe Behan walked.
The fact is that the over 70s medical card cost €220 million last year, while €86 million of this was attributed to GPs’ fees. Following all the brouhaha, the Minister has managed to save €16 million, which gives lie to the spin that this was all about GPs’ fees. It was more about the incompetence of a Minister who could have negotiated this with the pharmacists and the GPs, and left the over 70s with their medical cards and out of this row. She did not need to upset 350,000 pensioners and their families. Why did she not follow the internal advice given to her by the Department of Finance four days before the budget? Ultimately, she took that advice, but there was ample opportunity at the time to take a different route than the one she chose to take, which was to bring in the ban. She offered several different income levels and thresholds, which caused total confusion.
She maintains today that the bulk of people will keep their medical cards and that only 20,000 will lose them. However, the reality is that many people who are above that €700 gross threshold will not have a medical card. How many of these are retired schoolteachers, retired gardaí, retired nurses and other public and civil servants who have done the State some service? It is interesting to note that the IMO, in its submission, identified €80 million in drugs savings, which makes for €96 million in total when we add the amount saved by the Minister on fees.
I am very concerned about some of the provisions in this Bill. I obviously oppose the Bill, as I reject the Minister’s idea that universality is not something that is achievable or affordable. I contend that it is, and we will implement it if afforded the opportunity in Government to do so. However, the Bill requires people to declare after 2 March whether they are eligible. The Bill is not clear on the consequences of that, as it alludes to another section in another Bill. I would like the Minister to spell out what happens to somebody who fails a means test after 2 March. What happens to somebody who is not good at filling out forms or who has a fear of forms, such as somebody in a nursing home who might be mildly confused? It is not clear how this will work and what the consequences are for people. There is very little information on the means test and there is no information on the conditions under which people who wish to apply due to changing circumstances will be considered ineligible.
One of the major issues I have with this Bill is the line which states the Minister will review and may change the threshold, with the consent of the Minister for Finance. There are two caveats in there for people. Having seen the record of the Government in keeping promises, people do not trust the Minister to do that. They would much prefer to see “shall” in that line, and have the Minister for Finance removed from the equation.
Deputy James Reilly: I doubt it very much. Inflation for the current medical card system has been positive, but it has not changed in the last couple of years. We need to find out how we have arrived at a situation where the threshold has been set at little over half the minimum wage for the other medical card. If one has the temerity in this country to work, one does not get a medical card. The Minister has previously said that she is after millionaires with this measure. Gardaí, nurses and others are certainly not millionaires.
Deputy James Reilly: We would like to be absolutely assured of that. It would help, because otherwise it would represent another blow to the elderly. As this fair deal fund is capped, many people will not be able to avail of it. There will be a queue to get into nursing homes, but many will not be able to afford it. A third of people currently in nursing homes would not satisfy the criteria of high dependency to which the fair deal will be limited. Many people who find themselves in excess of €700 will have no money left because they are paying €50,000 per annum to a nursing home.
The Bill is not clear on what is included in the means test, and the Department of Health and Children has published no information on what it means by a “simplified means test”. Section 4(4) of the Bill states the calculation of gross income will include gross income from all sources. This includes pensions and investments, or savings with an income disregard of €36,000 for a single person and €72,000 for a couple, net rental income from property and any income from part-time employment. It is not clear how incomes on savings and investments are calculated, whether money gained from the sale of the principal private residence is considered, whether a person is eligible if he or she is in a nursing home and has income which exceeds the €700 threshold, but the cost of the nursing home care completely absorbs the income, or whether the person’s income is absorbed by excessive health expenses due to serious illness. What happens to siblings sharing a home and associated property and who have shared their expenses all their lives? Are they considered to be single or a couple? How is their property assessed? I know people in their 40s who have given up work to look after their parents, sometimes because one of the siblings is a bachelor and has continued to work in the home. If that person dies, do the circumstances change for the person who is still earning? Will the capital of any property other than the family home also be assessed?
How is the fluctuating nature of income on such investments to be calculated? Dividends and interest rates vary, sometimes dramatically. Will this mean that an individual may qualify for a medical card in one year, but lose it the following year? What about interest on post office products, savings bonds and savings certificates? Are these included in the calculation of gross income? Savings bonds are exempt from income tax, and the income levy is not paid on income from savings certificates, which is administered by the Revenue Commissioners. Will people who were encouraged to save under the SSIA be penalised for their savings? Is income from the rent a room scheme included?
The budget is changing the health expenses relief, yet the Minister tells us today that the Minister for Finance is not considering interfering with that relief. That is to be welcomed, but we would like to see it in the Act so that we can be sure of it, because there have been many U-turns recently.
People who are terminally ill have significant medical expenses. Many of them are above the limit, but historically they could apply to the HSE for a discretionary medical card and it would be given without any questions asked. Now they are being made jump through loops of red tape when they are at their weakest and most vulnerable. Many of them have been refused. We are not talking about millionaires, but about ordinary people. As I have said in the House previously, people who live in Walkinstown, Ballyfermot and many other places have been refused. The people in question are not millionaires. There is no guarantee that such people will receive a discretionary medical card. The means testing regime that is to be introduced was not previously in place. Medical cards were given to people who did not have long to live as a token of their service to the State. The provision of medical cards eased the concerns of such people about the cost of medical equipment, some of which is not available or is difficult to get outside the public health system. Are people to be deprived of morphine pumps? Will it continue to be possible for them to get hospital-type beds and commodes in their homes to allow them to stay at home? These are the sorts of things we are talking about.
I asked the Minister a straight question at a committee meeting last week. I asked her whether she would remove the cap on discretionary medical cards for the elderly and bring an end to the means-testing of such people. She did not answer that question in the affirmative. The Department of Health and Children contacted a newspaper to say that the Minister had indicated that it would be the case. I will give the Minister an opportunity to answer my question with a simple “Yes” or “No”. Will the cap on discretionary medical cards for the terminally ill be removed and will the means-testing of the terminally ill be brought to an end? I am quite happy for the Minister to answer the question now if she likes.
Deputy James Reilly: Many measures that will hurt the elderly were introduced in budget 2009. They will lose their medical cards. They will have to pay accident and emergency charges that have increased by €34 to €100 and public bed hospital charges that have increased by €9 to €75 a night. The cost of private beds in public hospitals has increased by 20%. The threshold for the drugs payment scheme has increased from €90 a month to €100 a month. Long-stay charges will increase by €33.25 a week for class 1 and by €24.95 a week for class 2. Health expenses relief, other than in respect of nursing home care, if we are to believe the Minister, has been reduced to the standard rate.
An article in today’s The Irish Times mentions the case of a 77 year old woman who lives alone. When she suffered a stroke, she fell and broke her hip. She was brought straight to the accident and emergency department in her local hospital. If she did not have a medical card, she would have had to pay an accident and emergency charge of €100. She would have to pay €100 a month for her regular medication and she would have had to pay for her GP visits. The article estimates that when drugs refund scheme charges, physiotherapy and occupational therapy and follow-up GP visits are taken into account, the cost of the loss of a medical card to such a woman would have been €1,920. The elderly cannot afford to pay that much money. That is why they are so concerned about medical cards. Age Action Ireland and the Irish Senior Citizens Parliament are vehemently opposed to this proposal. I do not understand why we cannot show solidarity with them.
This measure is penny wise and pound foolish. A longitudinal study that was conducted by St. James’s Hospital shows clearly that the introduction of universal medical card access for people over the age of 70 led to reductions in strokes, heart attacks and rates of hospitalisation. It brought about a considerable saving to the State and a considerable social gain for elderly patients. The word “hypocrisy” was mentioned earlier. I suggest that it is hypocritical to say one thing and do something else. I ask Deputy Treacy to bear in mind that hypocrisy does not involve changing one’s mind on the basis of new information, which is what evidence-based professionals are prepared to do.
According to figures published by the CSO, people over the age of 70 visit the doctor 5.2 times per annum. However, a recent study conducted by one of the largest general practices in the country found that people over the age of 70 visited the practice 11.1 times per annum. The increase in visits has resulted from the availability of medical cards. We need to monitor illness, which is more frequent and prevalent among the elderly. We need to prevent the complications that tend to land elderly people in hospital. We should not put a block, in the form of expense, between people and their GPs.
I would like to ask the Minister about the issue of nutritional supplements, which is being studied at present by a group led by Dr. Michael Barry. I hope the group will understand the value of these medicines. I refer, for example, to the fact that they are of great benefit to people who are elderly, malnourished or terminally ill, such as people with chronic illnesses who cannot absorb their food properly. Many studies have pointed to the glaring fact that malnourished people have much worse outcomes when they undergo surgery, particularly major surgery, than those who are properly nourished when they go under an anaesthetic. That is hugely important. I hope the focus will not be on saving money yet again, rather than on clinical benefit to patients. Section 7 of this legislation provides that current medical card holders who are over the age of 70 will have to make a declaration to the HSE by 2 March 2009. As I mentioned earlier, the Bill does not appear to accommodate those who might have difficulty making such a declaration.
I have already referred to the issue of universality. Many people are concerned that this measure represents the first step in the removal of the universal principle. They believe it will be followed by the abolition of universality in respect of the electricity allowance, the natural gas allowance, the electricity group account allowance, the bottled gas refill allowance, the telephone allowance and the free television allowance. People look forward to being able to avail of such allowances, having worked hard all their lives, when they pass the age of 70. They want to plan for the future without having to worry about expenses of this nature. Many people have told me they would give up their second pension rather than lose their medical card. This has been said publicly. That is how important the medical card is to them. They are keen to enjoy the comfort and safety of knowing they will be looked after, without money being an issue, if they get sick.
A major upset to the elderly of Ireland has been caused for the sake of €16 million. The former Deputy, Joe Higgins, used to complain that the former Taoiseach, Deputy Bertie Ahern, had stolen his clothes. It seems that Deputy Ahern took those clothes with him when he left office. He has left Fianna Fáil naked and bereft of any social conscience. It is clear that the Government has lost its compassion for the people. If that were not the case, it would not have instituted this attack on the elderly. What other conclusion can one draw? What party with a social conscience would rob the medical card from the elderly, cut tax relief on nursing home fees and increase VHI premiums? I ask the Minister to reverse this measure.
Deputy Michael Noonan: The withdrawal of the medical card from the elderly has been a disaster for the elderly, who will lose their cards, as well as for the Minister, the Government and Deputy Behan. It has been a fiscal disaster in the sense that it was originally intended to save €100 million but we have just heard that it will save €16 million.
Deputy Michael Noonan: I estimate the saving at €20 million, although Deputy Reilly has said it will be €16 million. In her introductory remarks, the Minister did not state how much she estimates this measure will save. When the Minister, Deputy Martin, introduced this political brainwave in the first instance, a couple of days before that year’s budget, it was a bit of a disaster. The Comptroller and Auditor General subsequently studied this issue and referred it to the Committee of Public Accounts. If I recall, the Government estimated at the time that it would cost €12 million or €13 million, but it cost over €70 million in the first year. The full-year cost at the time was approximately €115 million. The Accounting Officer responsible for it, the then Secretary General of the Department of Health and Children, explained that the Civil Service had been rushed into estimating the cost of the measure a couple of days before the budget. It did not have time to do a proper calculation. This system has a fairly ragged history, but we are where we are. The Minister would have been as well off to abandon it completely when she had to pull it back to such an extent under pressure from the Fianna Fáil parliamentary party. There are no great savings now and there is still considerable grief around. However, we are where we are and we have an obligation to try to improve the situation.
Those people who have medical cards already and whose income exceeds the new limits will get notification from the HSE and will be requested to own up if their income is in excess of the means test limit. The Minister’s colleagues in Fianna Fáil are effectively tacitly advising the elderly to lie. I have heard them on radio saying, “You’ll get the letter. Ignore it and you’ll hold on to your card. Don’t say anything. That’s fine”. However, the Minister has said that in many cases the Paymaster General would have an account. I heard her suggest in a radio interview that there would be cross-checking on pension income through the Office of the Paymaster General. She has been silent on the matter today. I wonder what the situation now is. Is there a tacit agreement in Government that when people get notice they will lose their medical cards if they are over the new means test limit, they should ignore the letter or is the Minister saying there will be cross-checking? If there is cross-checking and if later in the year people are found to have ignored the request to state their income, what measures will be taken? Are there penalties attached?
The Minister has reduced the means test provisions considerably. I do not know of any institution where a person can earn 5% on money on deposit. Even a month ago when interest rates were high, a person would not get 5% when the 23% or 24% DIRT is deducted. At present with interest rates dropping rapidly, to impute 5% to savings is not realisable and is not real income. The Minister is deliberately inflating the figures. I know there is a discount of €36,000 and €72,000.
Deputy Mary Harney: I wish to clarify to be helpful. We are not imputing any income. I said that in my comments. It will be based on actual income. Up to now income was imputed on property or whatever.
Deputy Michael Noonan: One category of people come to me quite regularly now lobbying against the change, which I ask the Minister to take into account. They are mostly women on State pensions who are widowed. They also have a social welfare pension — a widow’s pension or survivor’s pension. The combination of a teacher’s, nurse’s or garda’s pension and a social welfare pension is driving them over the limit. There are other social welfare payments which also drive people over the limit in restricted circumstances, including carer’s allowance etc. The Minister is exempting property from the means test. Somebody could have a house in Spain, a house in Kerry and a residence in Dublin. None of the residential property is taken into account. Yet if someone has a social welfare payment it is taken into account. The Minister would take much of the steam out of the opposition to the new measures if widows’ pensions were not put into the calculation of the means test.
Across the public service €36,400 is above most pensions for public servants. Most such pensions are in the low €30,000s rather than in the high €30,000s and I can see why the Minister pitched it at that level. However, if they have any social welfare benefit — many of them have, particularly widowed persons — that is driving them over the limit and they are all losing their medical cards. I received a circular letter during the week signed by 65 retired teachers in Limerick. Approximately 60 of them were women who were widowed and they were all losing their medical cards. I would like the Minister to reconsider that. The savings have been whittled away to such an extent that she should address that aspect.
There is confusion in the Department of Health and Children about what constitutes a couple. The Nursing Homes Support Scheme Bill 2008 regards a couple as a married couple, a heterosexual couple living as a married couple or a homosexual couple living together. It does not include two siblings or any such arrangement. This Bill contains a different definition of a couple. It seems to be a heterosexual couple, a married couple or a couple living together as a married couple and there are other exclusions. The Bill should include siblings as well. More than anything else the Department should standardise its definition of a couple. It appears somewhat perverse that different legislation can come from the Department of Health and Children with different definitions of a couple.
The conditions for qualifying for a medical card under the Bill are threefold. First, a person must be over 70. Second, the person must qualify under the means test. Third a person must be ordinarily resident in the country. I have come across a group of people who have previously been caught out on social welfare payments and medical cards by the requirement to be ordinarily resident in the country. The category relates to missionaries. Priests, nuns and brothers who have been on missions for years are not ordinarily resident in the country. When they come home they cannot get medical cards because they are not ordinarily resident in the country. Many of them come home on an annual basis when they become elderly. They may be home for two or three months. Others take time out and might be home for a year or six months and then return. Nuns in particular return to their home convent. They might stay for a significant stretch of time and then go back out again. That category is disqualified. They have contributed considerably. I need not go into the detail — we all know the work to which they have dedicated their lives. I ask the Minister to draft an amendment to allow a waiver of the requirement to be ordinarily resident in the country for persons involved in missionary or charitable work abroad.
There is another category. Increasingly laypeople volunteer upon retirement to work with Trócaire or GOAL. I know of retired teachers, doctors and engineers who work in the underdeveloped world. They are not ordinarily resident in the country. They do not work for money. They would be disqualified under the provisions of the Bill. I ask the Minister to review the matter with a view to framing an amendment.
As mentioned by Deputy Reilly, the Minister should consider another area of the means test, which is medical expenses especially nursing home expenses. If one’s total income is taken up by nursing home fees, that should not disqualify one from a medical card. We should also consider people who need to pay rent. Ordinarily people who fail the means test would have their own homes. However, for those paying rent, that rent should be taken into account as a reduction on the means.
I thank the Minister for her explanation. We are where we are and in the interest of trying to improve the mandate for the elderly I ask her to take some of my suggestions into account and table amendments.
Deputy Jan O’Sullivan: As I have already indicated the Labour Party will be vigorously opposing this legislation on all Stages. The universal entitlement to a medical card, which gives free access to primary care, for all over 70s must not be taken away. I again urge the Minister to reconsider her decision. What has happened since the budget has considerably watered down the original proposal. However, the inept way in which the change was introduced has shown that the Government is not in touch with the ordinary people on the matter. I believe the Minister will find that many of the people sitting behind her and voting for the Bill are not at all happy with taking away this universal entitlement.
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. Having a medical card allows such people to stay in their own homes longer. They get their primary care and also benefits such as visits from the public health nurse, the supply of incontinence pads if they need them, visits from a physiotherapist and chiropody. There is a variety of other benefits that come with a medical card, which have allowed many of our senior citizens to stay in their own homes and community rather than being in an expensive hospital bed.
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