‘Tinker with the health system at your peril’

The confusion created by the mess over whether over-70s will retain their right to a medical card has created huge uncertainty for the health service and the elderly, reports Aileen O’Meara. As the opposition loudly hammered government ministers in the Dáil last Thursday for abolishing the over-70s medical card, north Dublin GP Dr Mel Bates was trying to reassure a stream of his elderly patients that they had nothing to worry about: they were all still eligible for a full medical card on income grounds. ”They were talking about the lump sum their husband had left them 20 years ago and whether that would exclude them now,” Dr Bates said. ”I’ve had three patients in the past hour alone. There is a huge communications gap around this.” A ‘communications gap’ is a mild description of what happened following the initial announcement to end the over-70smedical card in last week’s Budget 2009. Huge political damage was inflicted on Mary Harney, the Minister for Health, for a misjudged move which if brought in would ultimately save the government little money, while creating an administrative maze for the HSE and the country’s oldest citizens. Instead of successfully selling the message that tough times mean tough decisions, Harney’s political judgment was damaged, her cabinet colleagues blamed her behind the scenes and the general public was angry and confused. An embarrassing climbdown was forced on her within two days of the budget, when she announced that eligibility limits for the card would be increased to match the old age pension. This was followed by a flurry of statements and outbursts from angry backbench TDs, including the resignation of Wicklow TD Joe Behan from the Fianna Fáil party last Friday. The debacle culminated in Taoiseach Brian Cowen’s turnaround on Friday night’s RTE news when he said he would be talking to doctors to see if the structure of the scheme could be changed. He said the process would begin before he leaves for the trade mission to China today but admitted that he had not yet contacted the Irish Medical Organisation (IMO) about possible talks. However, he insisted that the 100 million savings planned to be made from the scrapping of the automatic entitlement to medical cards for over-70s would have to be made from somewhere. He added that the scheme was ultimately unsustainable into the future. His unclear message only caused more confusion, and Fine Gael’s Enda Kenny said that, while the Taoiseach refused to reverse the decision, he ”bizarrely outlined no credible plan of action to deal with this fiasco”. ”The fact that he admitted that he hadn’t even contacted the IMO with a view to renegotiating the over 70s medical card scheme confirms to me that the government, and most particularly the Taoiseach, are all over the place on this crucial issue,” said Kenny. However, it was clear from the beginning that the Department of Health had not properly thought the move through. From last Tuesday afternoon, doctors all over the country were inundated with angry and confused elderly patients, struggling to find out if they were now faced, for the first time in their 70s, with paying for increasingly costly GP fees, medicine and services like physiotherapy. By this weekend, they were still as confused. It was clear that, while the move would be unpopular, it could be sold as something that only affected the w ell-off elderly. A total of 100 million would be saved, with 86 million coming from no longer having to pay higher fees to GPs, agreed in a poorly-planned deal by health minister Micheál Martin with the IMO seven years ago. Removing an entitlement that people had now taken for granted was always going to be unpopular, but the political storm engulfed Harney, as her colleagues had to deal with the anger resulting not just from the beneficiaries themselves, but their families, the general public and backbenchers. By Wednesday night, Minister for Finance Brian Lenihan was distancing himself from the move, isolating Harney to quell rising backbencher anger. Cowen tried to backtrack on this on Friday night, saying it was a cabinet decision. The opposition – led by Fine Gael’s Dr James Reilly, who had helped negotiate the deal as the GP representative on the IMO – made political hay of the misjudgment, helped by the considerable confusion around eligibility levels in the increasingly complex means-tested GMS (general medical services) scheme. Fine Gael called the move ”stupid and callous”, while Labour said the whole approach to scrapping the scheme ”has been characterised by bungling and incompetence.” While their calls to abandon the move were ignored, by late Thursday the department was ”clarifying” and ”simplifying” the income limits for eligibility for the medical card to match the old age pension. The ”clarification” also recognised that pensioners’ savings of up to 36,000 for a single person and 72,000 for a couple, would not be counted in the means test. Neither would the family home, the department added – a reminder of the ongoing controversy over Harney’s ”Fair Deal” plan, which will involve a deduction of up to 15 per cent of the value of a family home to pay for private nursing home care. But Age Action, a campaign group for the elderly, said that elderly people with even a few euro extra a week from a contributory pension would lose their medical card under these arrangements. They have called a public meeting for Tuesday on the issue, inviting politicians to attend, while the Senior Citizens Parliament is to hold a meeting outside the Dáil on Wednesday, where a Fine Gael Dáil motion on reversing the decision will be debated. Jan O’Sullivan, Labour’s health spokeswoman, said if the government wanted to make savings, it should renegotiate the ”lavish” fees negotiated with doctors in 2001, but retain the over-70s entitlement. The original decision to give free medical care to all over-70s may have been a political one, but the outcome – a fourfold increase in payments to GPs to treat patients – had beneficial effects at primary care level in some areas, though this was skewed in favour of better-off districts. Doctors in poorer areas prior to 2001 were paid four times less for caring for their patients than those who’d lost the private fees of wealthier patients. ”Many GP practices used the extra monies to employ staff, such as practice nurses, physiotherapists and practice managers, and provide more services,” said Bates, who is also spokesman for the Irish College of General Practitioners. ”Doctors invested in refurbishments or new practices. The college would recognise that it brought a lot of resources to general practice.” Older people’s health improved, thanks to high take-up of flu vaccines, regular checkups and the lack of worry about medical costs. Doctors agree that the vast majority of the new beneficiaries did not abuse their entitlements. ”The over 70smedical card removed the barrier to care,” said Bates. Prof Tom O’Dowd, a GP in Tallaght, Dublin, and professor of general practice in Trinity College Dublin, believes the arguments about eligibility should lead to a wider debate about access to primary care for everyone. ”People want more medical care, but they also want lower taxes,” he said. ”We also urgently need to do a review of the whole GMS contract. The public have to realise that you have to pay for a health service, but free primary care for all is affordable.” Earlier this year, the Adelaide Hospital Society published research carried out by TCD’s Health Management Unit, which showed that, using 2006 prices, free primary care for all would cost the exchequer 300 million over and above what is currently being spent on the medical card and the out-of-pocket costs of those who don’t have a medical card. ”The government could provide a free medical card for everyone at very little extra cost,” said the society’s director, Dr Fergus O’Farrell. ”The lessons of this debacle this week is that you tinker with the system at your peril,” he said.