Earning the right to a medical card

The Taoiseach says no, they are not. But countless people around the State say to the contrary that, yes, medical cards are being rationed by the Health Service Executive (HSE).

There are stories of abrupt cancellation of cards well before their expiry date; children with extensive medical problems being refused medical cards; and even cards being granted to family members who don’t need them and who never formally applied for them.

The Donaldson family, who live on the Carlow/Kildare border, are confused and stressed by their interactions with the HSE.

Matthew and Denise are the parents of three-year-old Matthew Jnr.

Matthew Jnr suffers with a rare chromosomal abnormality called WAGR syndrome (see panel).

He faces many challenges including a likelihood of developing cancer. And although chronologically aged 39 months, a recent assessment found he has the developmental age of a 13 month old. He cannot yet speak, is registered blind and uses hearing aids.

Matthew is also a behavioural challenge, and already displays some features of autism.

Medical need
When his parents first applied for a medical card for him, the application was made on the grounds of medical rather than financial need (the Donaldsons are not well off but do not qualify for a medical card).

A card was issued which expired 10 months later. On reapplication, the medical card was refused.

Following representations by a local politician, Matthew Jnr and his parents were granted a medical card for a year – even though the Donaldsons hadn’t looked for a card for themselves.

In April this year an application for a card for Matthew Jnr was refused. On appeal, he was granted a doctor-only medical card, while his parents were inexplicably issued with full medical cards.

Finally, a recent letter from a HSE appeals officer informed them that these full medical cards were being withdrawn: “The Medical Cards of Matthew’s parents were only extended pending the outcome of the appeal.

“These will now be withdrawn and a GP Visit Card set up for Matthew as per my appeal decision,” it says.

The last straw
Matthew Snr says giving him and his wife a full medical card, while his son got a GP-only card was the last straw.

“The HSE is giving him a card every child will be entitled to [under Government proposals to offer free GP care to all under- fives].

“But HSE, is every other three year old blind? Hearing impaired? Screened for tumours every three months? Attending physiotherapy, occupational therapy and speech therapy? Not talking? Diagnosed as having profound learning difficulties? Had seven various operations as well as four examinations under anaesthetic in their short life so far?

“Is that the level of care an able-bodied three year old requires?” he asks.

There are many stories of children with genuine long-term needs having their cards abruptly withdrawn before the renewal date.

Adam (not his real name) is a six year old who was born with a hypoplastic left heart – a condition where the main pumping chamber of the heart is underdeveloped.

He underwent life-saving open heart surgery but suffered a stroke following his operation.

He is looked after at home by his parents, but has significant needs in terms of equipment, medication and emergency care.

Suddenly cancelled
Adam has had a medical card for a number of years, with an expiry date of August 2014. However, his parents were shocked when his card was suddenly cancelled some weeks ago.

All of which is happening against an ever-growing HSE overspend for 2013 and plans announced in the budget to save €113 million by carrying out an exercise in medical card “probity”.

In a letter to the Minister for Health James Reilly, accompanying the HSE's draft service plan for next year, director general of the HSE Tony O'Brien said the total saving from primary care being targeted was €133 million.

However, Mr O'Brien said the scale of cuts envisaged to Medical Card services was being taken against the advice of both his organisation and the Department of Health.

The Orwellian sounding exercise is also being flagged as unachievable by Government sources; unfortunately, however, there may be considerable collateral damage inflicted on vulnerable individuals before common sense prevails.

Accessing services
People may be unable to access services in the community such as occupational therapy, physiotherapy and essential aids and appliances, the absence of which could precipitate an acute admission to hospital.

Despite reports of officials from the Department of the Taoiseach moving in to the Department of Health to deal with its ongoing challenges, Enda Kenny continues to insist there has been no policy change when it comes to issuing medical cards.

He told the Dáil that since the beginning of this year, 100,000 new medical cards had been granted, with 20,000 of them discretionary cards.

“Nobody is entitled to one automatically,’’ he added. “Everybody is entitled to have their case properly and compassionately assessed.’’ (See panel)

Denise Donaldson asks why can’t medical card eligibility be about need rather than income?

“Leave age and income out of it. We need a system that provides a medical assessment card rather than a cost card,” she says. It’s a logic that is hard to find fault with.

Medical Card: numbers and eligibility

According to the 1970 Health Act, income is not the only factor that must be taken into account when deciding eligibility for a medical card.

Under the Act, a person is entitled to a medical card if they are “unable, without undue hardship, to arrange general practitioner, medical and surgical services for themselves and their dependants”.

More than 45,000 people have had their medical cards removed this year following the biggest ever review of eligibility conducted by the HSE.

The status of 428,000 cards had been reviewed by the end of October this year, resulting in almost 10,000 people who were found to be ineligible, while 35,733 did not respond or provide sufficient information.

GPs are paid a flat annual capitation fee, which varies according to the patient's age. Apart from a handful of special type consultation fees, it means doctors are paid the same if a person attends once a year or every week.

WAGR syndrome: What is it?

Matthew Jnr is one of only 400 people in the world with WAGR syndrome.

Caused by a deletion in Chromosome no 11, the name represents an acronym of some of the health problems associated with the abnormality.

W stands for Wilm’s tumour, a cancer of the kidneys. A is for aniridia, the medical name for the absence of the coloured part of the eye.

Other eye problems experienced by children with the condition include glaucoma (an increased pressure within the eyeball) and abnormal eye movements(nystagmus).

G is a reference to the genitourinary anomalies that occur, the most serious of which is the development of tumours in the testes or gonads.

R represents retardation, a reference to developmental delay and intellectual disability.

A number of people with WAGR syndrome develop severe childhood obesity, while some are born with ears that are set lower than usual on the head.