I welcome this opportunity to address the House today on the Government’s commitment to extend medical card provision to all children in receipt of the Domiciliary Care Allowance (DCA), as we set out in our agreed Programme for a Partnership Government.
I would like to acknowledge at the outset that there is broad agreement on this issue and that no one political party holds a monopoly of concern for the parents and children who need to see this policy implemented. While I welcome the Sinn Fein motion as an opportunity to outline the next steps, as I have already outlined them at a meeting with the Our Children’s Health campaign, I think it is important to say that no Dail motion was necessary to convince me to do this. I have been convinced by the people who are here in the gallery tonight. I have been convinced by the parents of children who are in receipt of Domiciliary Care of Allowance, the parents I have met in my own constituency, the parents of children with autism who I have worked with for many years.
In fact, on my way into one of my first Cabinet meetings, I spoke with one of the Our Children's Health campaigners outside Government buildings. Many of us, as public representatives, have been struck by the practical challenges that parents face in meeting the needs of their child with a severe disability. As we discussed the issue that day, I came to understand that, for many of these parents, meeting their child's needs was the first time that they had sought assistance from the State. The process of providing family financial information, expert or medical reports, and additional supporting information was a real burden on these parents when they were only seeking a medical card for their child. I am very clear that a core objective of the Government is to use the strengthening economy to make life better for the Irish people.
The Government has committed to this significant improvement to the medical card system for a number of reasons:
• Firstly, about one-third of DCA children do not hold a medical card. Therefore, about 11,000 more children with a severe disability will qualify for a medical card.
• Secondly, in future, all 33,000 DCA children will automatically qualify for a medical card. Therefore, these children will not be subject to the medical card means-test in the future.
• Finally, the requirement to go through the medical card assessment process will be removed for about 30,000 families looking after a child with a severe disability. These families will no longer need to complete a means test application form for their child and support this expert reports and other additional information in order for their child's case to be considered. Instead, mothers and fathers will be able focus on providing care and support to their child.
Last week, I held a meeting with representatives of the Our Children’s Health campaign in my office. At that meeting, I reaffirmed the Government's commitment in its Programme to providing medical cards to all children that qualify for the DCA. I confirmed that this commitment was a priority for me in the upcoming budget discussions and that my objective was to have legislation to enable it follow quickly after the required resources have been secured.
I think that it fair to say that all assessment systems have some limitations. It is probably practically impossible for a single assessment system to take account of all individual circumstances. If one tried with the best will in the world, it would probably become incredible complex. While it is important that we acknowledge the limitations of the existing eligibility framework, it is also necessary to recognise the potential for improvements that we can make.
I believe that the recently established Committee on the Future of Healthcare will play a key role in this regard. It was set up to achieve cross-party consensus on a single long-term vision for health care and the direction of health policy in Ireland, and to make recommendations to the Dáil. I firmly believe that the health service will benefit greatly from a single unifying vision that we can all get behind. A long-term vision, built on a cross-party or even a social consensus, can help to drive reform and development of the system over the next 10 years.
I am genuinely excited that the new Dáil has come together with the aim of achieving a long-term consensus on the fundamental principles of health policy. In striving for the optimal single-tier health service for Ireland, there are inevitable policy trade-offs to be confronted. These trade-offs often involve tensions between efficiency and equity or between comprehensiveness and cost control. In all countries – not just Ireland – the trade-offs centre around three basic dimensions of the health service which must be confronted when designing a health service:
• the proportion of the population to be covered;
• the range of services to be covered; and,
• the proportion of the total costs to be met.
Turning to the specific issue, Deputies may be aware that the DCA is administered by my colleague, the Minister for Social Protection. It is a monthly payment for a child with a severe disability, aged under 16 years, who requires ongoing care and attention substantially over and above the care and attention usually required by a child of the same age.
I accept that this DCA measure is not the perfect solution to our health eligibility framework. The latest available data indicate that about 33,000 children qualify for the DCA. By comparison, about 390,000 children under the age of 16 years currently qualify for the medical card. The DCA is not based on a type of disability or the medical need of a child. Under the legislation, it is based on the how much extra care and attention a child needs because of it. The DCA also has a range of qualifying criteria. These include the disability being likely to last for at least one year, that the parent is providing the care to the child, that the child resides at home, and the child meeting the medical criteria of the scheme.
Recently, I visited the HSE’s National Medical Card Unit, which administers the General Medical Services scheme. Its functions include the processing of medical card applications. The NMCU was established in 2011 as part of the HSE’s Primary Care Reimbursement Service (PCRS). I would like to acknowledge the hard work of the staff of the Medical Card Unit that I met. I know that they are committed to ensuring that anyone, who is eligible for a medical card under the existing legislation, receives their card, and that the system operates in as streamlined and as user-friendly way as possible. The Medical Card Unit provides a single uniform system for medical card applications and renewals, replacing the different systems previously operated in the local health offices. This ensures that people are treated in a similar manner irrespective of where they live.
The scale of the operations of the National Medical Card Unit is enormous. In 2015 alone, the Medical Card Unit processed almost 400,000 cases. These included 107,000 new applications and 92,000 full reviews of medical card and GP visit card eligibility, as well as, over 195,000 self-assessment reviews of eligibility. Currently, there are over 1.7 million people registered with a medical card and a further 450,000 people registered with a GP visit card.
Under the existing health legislation, the standard assessment for a medical card is based on the combined income of the applicant and spouse or partner, if any, after tax, PRSI and Universal Social Charge have been deducted. In addition, a further allowance is made for the costs of rent or a mortgage, travelling to and from work, and the costs of child care that a family might face. In the assessment process, the HSE can take into account medical costs incurred by an individual or a family. Where deemed appropriate in particular circumstances, the HSE may exercise discretion and grant a medical card even though an applicant's means exceed the relevant threshold.
Deputies may be aware of a major report in 2014 by the Expert Panel on Medical Need for Medical Card Eligibility, which was chaired by Professor Frank Keane. The Keane Report recommended that a person’s means should remain the main qualifier for a medical card and that it was not feasible, desirable, nor ethically justifiable to list medical conditions for medical card eligibility. Nonetheless, it is clear that there are people – including children - with medical needs and it is important that they should be able to access necessary assistance in a straight forward manner.
On foot of the Keane Report, the HSE established the Clinical Advisory Group on medical card eligibility to develop a framework for assessment and measurement of the burden of disease and appropriate operational guidelines for the medical card scheme. The membership of the Clinical Advisory Group includes clinical experts from specialist services and professions, as well as patient representatives. The Group reports to the National Director of Primary Care on a quarterly basis. It is expected that the Group will make a report to the Director General of the HSE when it has completed its work in the near future.
As a result of a range of improvements implemented by the HSE on foot of the Keane Report, the HSE is exercising greater discretion. There are now over 106,000 discretionary medical cards. This is the highest number of discretionary medical cards on record.
In conclusion, I welcome this opportunity to address the House today on the Government’s commitment to provide medical cards to all children in receipt of the Domiciliary Care Allowance.
As I said at the outset, this is a key Programme for Government commitment. This commitment is a priority for me in the upcoming discussions on Budget 2017. I am privileged to have become Minister for Health at a time when we are in a period of reinvestment in the health services, which gives me the opportunity to address some immediate issues facing patients as well as meeting Programme for Government commitments.
However, as Minister for Health, I also recognised that there are enormous demands and cost pressures on our health service. Health care demand continues to rise due to our growing and ageing population, the increasing incidence of chronic conditions and advances in medical technologies and treatments. We have secured a substantial increase in funding for the health services for 2016 but I do not underestimate the challenges involved in the delivery of a safe efficient health service for Irish patients. Health systems all around the world are struggling with the issue of rising costs – Ireland is in no way unique in this, and maintaining the pace of reform is fundamental. We must maintain our focus on improving the way services are organised and delivered and reducing costs in order to maximise service provision. There will continue to be a need for Government to consider a range of development priorities, to strike the best balance between them and to prioritise additional investment in our health services, in 2017 and beyond, from within the limits of the finite resources that are available to Government as a whole.
I am very hopeful that I would be able to get cross-party support for legislation that would give effect to this measure. This would allow for it to pass quickly through the House so as to bring the benefits to these children and their families in the not too distant future. I hope that not having to worry about applying for a medical card will help these 30,000 families in some small way.