Government must tell us how it'll deliver healthcare to those who need it the most
When government parties got hammered in the local and European elections over sick people losing their medical cards they did two things. Uncharacteristically, they admitted some wrongdoing and re-issued 13,300 discretionary medical cards that had been taken away. They also set up an expert panel to advise about how best to allocate medical cards on the basis of medical conditions.
The key finding of the expert panel's report - that it is just not possible nor desirable "to list and prioritise conditions for full medical card eligibility" - has been leaked, but there are many other considered and important recommendations that are not yet in the public domain.
The expert panel found that the medical card scheme - despite public discontent and confusion caused by it - is of merit for "the majority who gain access to it on the basis of low financial means". They acknowledge that the medical card scheme has "evolved over time in a fragmented manner", is "complex and poorly understood by patients, medical staff and administrators", how some people thought medical cards were for life and the unfairness of the huge post-code lottery of getting a card.
Their report recommended the medical card system be made simpler and more explicit, with a comprehensive suite of material to ensure transparent, ethical and compassionate medical card application and renewal processes.
The panel recommended that financial testing should remain the main mechanism "for selecting the majority of those eligible for a medical card", but critically that the means testing for medical cards should be carried out by a third party, not the HSE. Since March 2013, the HSE, Revenue Commissioners and the Department of Social Protection share records, is the next move for Revenue or Social Protection to be the means tester for medical cards?
There was extensive public consultation, which informed the work of the expert panel, with over 3,250 submissions. Key findings from these reveal that people want medical cards allocated according to medical need rather than just having a condition.
Interestingly, the expert panel suggested separating out the allocation of a medical cards from other benefits that one is automatically entitled to, such as reduced Universal Social Charge payments, waived charges for FOI requests, school transport and exam fees. This would be a major shift, as some of the value given to medical cards is due to the non-medical benefits.
The report repeatedly highlights how the system of allocating medical cards does not discern the true cost of illness for those without medical cards, especially those with conditions which require the cost of medication up to €144 per month, frequent visits to the GP at €40-60 a visit, as well as having to pay for additional therapies, aids or appliances themselves.
The issue of what healthcare one is entitled to - with or without a medical card - also raised its ugly head. Currently, all citizens are technically entitled to public health nursing, public physiotherapy, occupational therapy, speech and language therapy services, but there are variations across the country - and in some areas some people do not gain access to such services without a medical card. They recommend uniformity and universality for these services, with access allocated on the basis of those in greatest need.
Currently access to aids and appliances without charge, necessary for living at home with an illness or medical condition, are only provided to medical card holders. The expert panel recommends that this should not be the sole qualifying criteria for what can be essential, but often expensive, ways of meeting health needs. There are key recommendations in relation to the better allocation of discretionary medical cards in the future.
It suggests that they are only given to that individual, not their entire family unit as is currently the case. It also suggests that there should be greater compassion in assessing the discretionary decision-making process, including an assessment of the burden of the medical condition(s), that those allocated them with a terminal illness should keep them for the remainder of their life. The expert panel does not underestimate the "significant challenge" in doing this, especially to do so in a transparent way, against the competing pressure coming from the Controller and Auditor General, who wants increased vigilance and rigidity on medical card allocation.
The expert panel clearly endorses government policy of delivering free GP care for all and universal access to primary care services. They also discretely make the point that none of this complex, burdensome administration would be necessary if we had universal health coverage - as in most other OECD countries.
The extent of public concern over medical cards is aptly captured in this report - the HSE section that deals with medical cards receives around 4,000 calls or queries every day, for example.
This is a really good report which makes a significant contribution to a much-needed national dialogue on who accesses which healthcare services and how. Minister for Health Leo Varadkar has indicated his response in proposing a streamlined, more compassionate application system whereby a doctor will assess medical need even if the family does not meet the means-testing criteria. He has also restated his commitment to universal healthcare.
Minister, publish this important work now, put us out of our misery and tell us how your government plans to deliver on its promise of access to medical care on the basis of medical need.
Sara Burke is a health policy analyst and a research fellow in Trinity College Dublin