· The legislative basis for the medical card scheme is the 1970 Health Act. This provides for the granting of medical cards on the basis of undue financial hardship. In other words, by law, access is governed by a means test.
· During the course of the economic crisis very challenging budgetary targets have been set. To try to reach those targets, the HSE is required to review eligibility for medical cards, to ensure that scarce resources are targeted at those in greatest need.
· The HSE has discretion to be more flexible for those with on-going medical conditions, but we know that this has not been applied in a consistent way. For example, in 2009, only 3 discretionary cards were issued per 1,000 of the population in Meath, while in north Cork, there were 53 cards issued on this basis – more than 17 times as many as in Meath.
· That is why the last government’s decision to centralise administration of medical cards was overturned, because the discretionary system was clearly not operating fairly.
· Although medical expenses can be included in the means assessment for people with serious health conditions (and greater discretion can be used in those cases) the test of undue financial hardship still has to be met. This has meant that some people who do have on-going medical conditions remained ineligible for a medical card even when their medical expenses are taken into account.
· In light of the very difficult economic circumstances, it has become clear that the legislative basis for the medical card scheme – which is nearly 45 years old – no longer meets the needs of Irish society.
Moving towards universal coverage for GP care free at the point of use
· The Programme for Government signalled the intention to provide universal access to GP care free at the point of use, via a move to universal health insurance. The government’s intention was to prioritise people with serious medical conditions, and the Long Term Illness Scheme could provide a basis for this.
· However, legal advice was that this would be vulnerable to challenge – the list of conditions covered by the LTI scheme is not based on any objective criteria or evidence. Rather, it reflects political choices made over the years to include some conditions, but not others.
What did government announce yesterday?
· The decision of the Cabinet Committee on Health respects a key Programme for Government commitment – to ensure that those with serious on-going medical conditions are prioritised in the roll out of universal access to GP care. Government wants to provide a new ground of eligibility for medical and GP visit cards – that of having a serious on-going health condition – in addition to the financial hardship ground (which requires a means test). This will include the development of new legislation, as necessary.
· The government has requested the HSE to establish an Expert Panel, with the required clinical expertise, to advise it on the medical conditions that should be covered and on the kind of services and supports that people with those conditions are likely to require.
· The Department of Health has also been mandated to develop a policy paper on the further rollout of GP care free at the point of use, in the context of the move to universal health insurance.
· This decision shows that government has clearly heard the people’s views.
What is the timeframe?
· This work should be conducted as expeditiously as possible. The Minister for Health will bring a Memorandum to Government setting out the key parameters of the conclusions of the Cabinet Health Committee on Tuesday. The Expert Panel will be established as quickly as possible, and will be expected to produce a report in advance of the estimates process for Budget 2015.
What does this mean for people with cards awarded on a discretionary basis?
· The HSE has decided to suspend further reviews of medical cards where discretion had been used to take account of medical circumstances, pending the outcome of this process. This suspension will include people who are currently appealing a decision to withdraw a card.
· Where people have lost eligibility for a discretionary medical card and have unsuccessfully completed the appeals process, government unfortunately does not have a legal basis to restore those cards immediately. However, the Expert Panel will be asked to make an early recommendation on this issue, so that meeting the needs of this group will be prioritised.
· The aim is to provide a new legal ground on which people with serious on-going health conditions can access a card without a means test. In the interim, the HSE is putting in place a process to ensure that people are benefiting from the full range of health services and supports available – as many of these are available without a means test (see below).
Bringing the local back in – local integrated care packages
· The medical card scheme was never intended to operate in isolation, but rather as part of a range of schemes and supports provided for under the Health Acts and various administrative arrangements.
· One unintended consequence of centralising administration of the medical card scheme is that people with on-going serious health needs, and who are not eligible for a card, may experience difficulty in understanding and accessing the full range of health services and supports that are available, many without a means test.
· To re-establish the benefits of a localised approach to meeting health needs, the HSE is putting in place a process to deliver integrated packages of care. This will be focused, in the first instance, on households who have lost eligibility for a medical or GP visit card provided on a discretionary basis
· It is intended that a nominated HSE liaison officer will contact each household where medical evidence submitted indicates an ongoing care and support need. A key worker will be assigned to each case at local level to coordinate access to services on behalf of those with medical care needs. Services may include – for example – supports in relation to the provision of drugs and medicines, the long term illness scheme, therapy services, dental, ophthalmic and aural services, supply of equipment, aids and appliances, hospital services and rehabilitation services etc.
How will this be funded?
· Eligibility on the basis of medical need: The government will make decisions on extending access to medical and GP visit cards – along with other relevant health services and supports as advised by the Expert in the context of the estimates process for Budget 2015 (Due in September/October of this year)
· Children under 6:Additional earmarked funding of €37m was provided in Budget 2014 to fund free GP care for children under 6. It is not funded through cuts elsewhere in the health system. New legislation is required to implement this, which has not yet passed through the Oireachtas, so this funding has not yet been spent.
· Medical and GP visit cards: Under current legislation, medical and GP visit cards can only be granted on the basis of a means test (to demonstrate financial hardship). In recent years, the health service conducted probity reviews, to ensure that scarce resources are targeted at those in greatest need. The target for probity savings originally set in Budget 2014 was to achieve a total of €133m in savings. Subsequent to a validation process requested by Minister Reilly, this target was subsequently reduced to €23m.