People throughout the country are receiving letters notifying them of a review of their medical card eligibility and entitlements. In many cases, medical cards are being taken away from people, which causes great anxiety and distress to them. Within this general cull of medical cards there has been a particularly nasty focus on those with serious illnesses who had discretionary medical cards. They may have been over the income threshold but because of the seriousness of their medical conditions, including cancer and motor neurone disease, they were in receipt of a discretionary medical card.

The figures tell the story. A few years ago, about 80,000 people were in receipt of discretionary medical cards but that figure has now fallen to 56,000. That reduction of 24,000 discretionary medical cards within the system affects young children with multiple complex conditions, many adults with severe illnesses, as well as incapacitated senior citizens. It is a nasty, underhand and sneaky attack whose bottom line is to save money. It is hitting the most medically compromised within our health service. It is hitting patients who can least afford to lose their medical cards because of the additional expense and costs associated with their illnesses and medical conditions.

There have been ongoing official denials about this matter from the Taoiseach, the Tánaiste - as late as last Thursday - and the HSE. I was struck, however, by a letter published in The Irish Times on 25 July 2013 from Professor Orla Hardiman.

A question, please.

She said she had read with interest a statement from the HSE indicating that those with severe and life-threatening illnesses would continue to receive medical cards. Professor Hardiman wrote:

I am puzzled by the disparity between the policy as enunciated and our recent experience in the motor neurone disease clinic. Within the past few months, I have drafted many letters to the HSE in support of appeals by people with advanced motor neurone disease who have been refused medical cards.

Will the Taoiseach reverse this policy and restore discretionary medical cards to those who have had them taken away?

I thank Deputy Martin for his question. There has not been any change in the policy that is adopted here. The number of people with free access to GP care is now the highest in the history of the State. Some 43% of people now have access to free GP care, while 40.7% have medical cards and 2.72% have GP visit cards. In the past two and a half years, there have been an extra 250,000 people with access to and eligibility for free GP care. As of 1 August 2013, some 1.866 million people have a full medical card and a further 131,000 have a GP visit card, which is a total of 1.991 million.

When the Government was elected to office, discretionary medical card applications were not routinely assessed by medical personnel. The Minister for Health, Deputy Reilly, instructed the HSE to establish a clinical panel to assist in the processing of applications for discretionary medical cards. This process allows for medical professionals to have an input into granting a medical card to people who exceed the income guidelines but who face difficult personal circumstances, such as a particular illness. We all know people who are in that category. Discretionary medical cards are awarded to people who are unable, without undue hardship, to arrange GP services for themselves and their families.

The number of discretionary medical cards has fallen because more than 22,000 such card holders now qualify for an ordinary medical card as they now meet the income eligibility. Since 2011, 22,584 individuals who were previously recorded on the medical card register as having eligibility for discretionary medical cards are now registered as ordinary medical card holders because they meet the income eligibility.

The HSE is entitled to award medical cards only in accordance with the Health Act 1970, so applicants must be assessed. The Act states that persons who are "unable without undue hardship to arrange [GP] ... services for themselves and for their [families]" qualify for a medical card. Therefore there is not, and never has been, an automatic entitlement to a medical card for persons with a specific illness. That is the position as outlined in the Health Act 1970, to which I have referred. There is no legal basis for what people might call a cancer medical card or a motor neurone disease card. Of course, that does not mean that in applying the assessment, those people do not qualify under particular circumstances for a medical card.

There is also the question of discretionary medical cards in emergency situations. A system has been put in place for the provision of emergency medical cards for patients who are seriously ill and who are in urgent need of medical care that they cannot afford. Emergency medical cards are issued by the HSE within 24 hours of receipt of the required patient details and a letter of confirmation of the patient's condition from a doctor or medical consultant.

With the exception of terminally ill patients, the HSE issues all emergency cards on the basis that the patient is eligible for a medical card on the basis of means or undue hardship, and that the applicant will follow up with a full application within a number of weeks of receiving that emergency card. As a result, medical cards are issued to a named individual with a limited eligibility for a period of six months. This is always applied with the flexibility that community welfare officers used to have.

There is a slightly different interpretation of discretionary medical cards for persons who are terminally ill. Once the terminal illness is, unfortunately, verified, patients are given an emergency medical card for a period of six months. Given the nature, urgency and sensitivity of that issue, the HSE has put in place an expeditious process to ensure such people receive those cards as quickly as possible, and rightly so. Therefore, the HSE ensures the system responds as quickly as possible to the variety of circumstances and complexities that such individuals face in what are traumatic personal situations.

I am not talking about the general population because the number of medical cards currently being issued is a function of joblessness. High unemployment equals higher numbers of medical cards being issued. I asked the Taoiseach a specific question on discretionary medical cards. In many ways, however, his answer is in denial of the reality on the ground. I quoted Professor Orla Hardiman from the motor neurone disease clinic as stating: "I have drafted many letters to the HSE in support of appeals by people with advanced motor neurone disease who have been refused medical cards." That rubbishes everything that Taoiseach has just said. Professor Hardiman added: "I have also written many letters for people in the terminal stages of their illness, whose medical cards have been withdrawn for reasons that are entirely unclear."

That letter was published in The Irish Times on 25 July 2013. In an article on 7 August 2013 by Paul Cullen dealing with this specific issue, Professor Hardiman again rubbished claims that emergency medical cards were issued to terminally ill patients within 24 hours, stating they were "simply untrue".

Files in my constituency office include that of a 12 year old boy with serious health issues who was refused a medical card. In addition, a six year old boy with very complex medical issues was refused a medical card. A number of adults with complex medical issues have also been refused medical cards. I am not talking about holding on to their discretionary medical cards. The cards were taken from them or applications were refused.

The Deputy should put a supplementary question.

People who hear responses from the Taoiseach, the Tánaiste and the HSE cannot equate them with the reality on the ground. That is the experience of most Deputies here also, given the numbers of people who have come to them in the past year. Last year's budget signalled that about 40,000 medical cards would be taken out of the system.

It is those who are medically most compromised who are suffering. There is no point telling me there has not been a change: there has been a change and most people on the ground are experiencing it. The Taoiseach needs to dig deep and ensure this change is reversed.

I am sure Deputy Martin will agree that following the change to central processing, applications for medical cards or discretionary medical cards are now all treated on the same basis. For years we had a situation whereby individual community welfare officers, based on their assessment, could make a recommendation for the issuing of a medical card as applied under the old health board system. Any Deputy who served in this House will have engaged in that process in respect of cases brought to their attention by people in different circumstances seeking to be awarded a medical card.

In the case of applications for discretionary medical cards or in respect of persons with a serious or terminal illness as I have already stated a process is in place for the issuance of an emergency card for a six month period but it must be based on medical evidence. The Deputy mentioned a particular case. I would like him to make the details of that case known to me, if possible.

This is systemic.

There are many such cases.

The Taoiseach's time is almost up.

As an elected representative, particular claims are also made to me. The bottom line is that more than 22,000 people who previously held discretionary medical cards do not now have them because they are eligible for an ordinary medical card. Since this Government took office, more than 250,000 additional people who previously did not have a medical card have been awarded one. We now have the highest ever number of medical card holders in the history of the State. The Government wants to proceed to a process whereby we have the best health system, which will respond quickly to the needs of people in any of the categories mentioned by the Deputy.