Handing out medical cards on the basis of illness is the wrong way to go

Opinion: Resources will inevitably be taken away from others with greater financial need

‘We’ve been down this dubious road of universal entitlement before. Free university fees were sold as the way to get working class kids into college but ended up overwhelmingly subsidising the education costs of the middle classes. The distribution of free medical cards for all over-70s had to be reversed within a decade.’ Above, people taking part in a protest about  medical cards for those aged 70 and over, in 2008. Photograph: Eric Luke

‘We’ve been down this dubious road of universal entitlement before. Free university fees were sold as the way to get working class kids into college but ended up overwhelmingly subsidising the education costs of the middle classes. The distribution of free medical cards for all over-70s had to be reversed within a decade.’ Above, people taking part in a protest about medical cards for those aged 70 and over, in 2008. Photograph: Eric Luke

Wed, Jun 11, 2014, 00:01

Given the debate that has taken place over the last month, you might be forgiven for thinking that a harsh bureaucracy, egged on a heartless political class with no mandate, has savagely ripped medical cards out of the hands of sick children and their families.

There may be some truth to the various elements of this statement, but it is hard to find. There has been a drop of 30,000 in the number of discretionary cards, and a drop of about 55,000 in the total number of medical cards.

Some of these changes are due to people being moved between the different variants of card, others are a result of people returning to work.

The centralisation of card processing has hit people living in areas where discretion was being applied more generously than elsewhere. About 3 per cent of reviews of discretionary cards has resulted in removal.

Scores of cases have been reported in the media in which people have cried foul over the removal of cards, or the refusal to grant cards. Even Government Ministers have said they couldn’t stand over what happened in some of these cases.

Problematic decisions

But the tone and scale of the problem as portrayed in reports is well wide of the mark. Problematic decisions, while they exist, are a small fraction of the overall number of card reviews. There are appeal mechanisms and fallback entitlements in situations where a medical card has been refused.

The State is not miserly in the granting of medical cards. There are almost two million in circulation, so the poor and the low-waged are covered.

There are times of illness when our medical needs soar, possibly beyond our means. That’s why the discretionary process is there. The exercise of discretion in granting a medical card wasn’t working very evenly, with patients in some parts of the country six times more likely to get a card this way. Or, more pertinently, patients in other parts of the country were six times less likely to get a card through the exercise of discretion.

Where a person fails to qualify for a medical card, there are other options. They may yet qualify for a GP visit card, which doesn’t cover the cost of drugs. For certain conditions their medical costs will be covered by the long-term illness scheme. It was wrong that successive ministers refused to update the list of conditions covered by the scheme.

Drug payment scheme

The next fallback is the drug payment scheme. Thresholds here have been raised but at present no family (not individual) has to pay more than €144 a month for drugs.

That caps their spending at well under €2,000 a year, a sizable sum without doubt but one that upper-middle class families should be able to afford.

Little of this context was provided in the highly emotive presentation of the controversy over recent months. Claims that people were asked by officials if they “still had MS” or if their child’s Down syndrome “has got better” became part of the folklore.

Febrile atmosphere

It’s not that people made up these claims, more likely the explanations offered by officials were interpreted wrongly in a febrile atmosphere. The Health Service Executive isn’t always to be taken at face value but it would hardly be offering people the chance to listen back to recordings of their phone calls if it didn’t think it was on firm ground.

Many of those who lost their discretionary medical cards were many multiples over the income limits for a regular card but this fact was routinely ignored.

So where are we now? Medical card legislation has been around for 44 years but the Government is proposing to change the rules in three months. Two years after citing legal obstacles to granting entitlement to free GP care on medical condition rather than means, it is suggesting that a similar change can be made without even touching the legislation.

Not surprisingly, patient groups are queuing up to have their condition included in the revised scheme. Consultants will come under ferocious pressure to provide the certification that qualifies a person for a medical card on clinical grounds. The nod and wink will rule again. The lawyers will be busy.

If we had the resources, this wouldn’t be a problem. But we don’t and we’re going to have even fewer again in the coming years. It’s not just our economic woes that are to blame; in the United States, due to medical inflation, health spending would consume the entire state budget in 20 years unless checked.

So the money we have has to be allocated wisely and fairly. There is still waste in the health service but not nearly as much as before almost €4 billion was cut from spending in recent years.

Uncosted proposal

The uncosted proposal of the Government to give cards to people with certain medical conditions regardless of means will inevitably result in resources being taken away from others with greater financial need. Yet among Government Ministers only Pat Rabbitte has had the courage to say this.

We’ve been down this dubious road of universal entitlement before. Free university fees were sold as the way to get working-class kids into college but ended up overwhelmingly subsidising the education costs of the middle classes. The distribution of free medical cards for all over-70s had to be reversed within a decade.

The solution to the present medical card issue lay in the Government standing up for what was right, not what was popular. It lay in improving the processing of medical card applications better so that the needs of patients were put first, bureaucracy reduced to a minimum and discretion applied humanely and evenly.

Paul Cullen is Health Correspondent

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