The Irish Medical Times - Discretionary medical cards, the Willy Wonka golden ticket


Although a medical card is associated with means testing, there are exceptions where it is given on other grounds, including people affected by thalidomide, or women who have had a symphysiotomy. Both are harrowing examples of unnecessary suffering that led to public controversy where the government felt a response was required. 


From a patient perspective, aside from the government allocating cards as reparations or awarding them to those successful in proving their burden, discretionary medical cards could be allocated based on a diagnosis, for example, heart failure. There are other chronic conditions that deserve a medical card but I am concentrating here on heart failure as that is my own lived experience. The European Society of Cardiology has marked 2th-8th May 2022 as Heart Failure Awareness Days - so please put on your listening ears (to borrow the expression from my daughter's school teacher, her other favourite literalisms include ‘look at me with your eyes’ and ‘faces forward’ - I know a person's head can turn but their actual face is usual pretty much always forward, unless perhaps you’re two faced).  


With chronic illness such as heart failure the patient is often limited in their energy and buoyancy, they often cannot work, they may find themselves in a situation where they have dependents to support yet they alone shoulder the cost of staying alive. The price tag includes endless vital daily medications, consultant fees, frequent GP visits, tests, scans, bloods, rehab, transport to appointments/hospital, childcare, homecare, counselling, higher insurance, supplements, comorbidities and their spin off costs, it can seem never ending.

When the founder of SCAD Ireland and heart patient advocate Pauline O’Shea was asked about medical cards for heart failure patients, she put it succinctly, "It is simply unjust, impractical and immoral that they are not allocated a medical card based on their condition."


Medical cards are provided on a compassionate basis to people who have 2 years to live. ‘Time to death’ is a driver in these decisions as the last 2 years of a terminal illness are expensive, with the last 6 months being very pricey (presumably with the extra care required, plus the farewell trip to Hawaii, abseiling down a waterfall, swimming with sharks and other bucket list items the HSE now pays for). 


This ‘Time to death’ is based on an experienced prognosis but I always marvel at doctors' sidelining in time trading. Give up cigarettes, that will add  20 years to your life, excessive alcohol consumption, that’s 10 gone right there, fond of fry ups, that’s another 5 gone but I’ll add back 3 because you do eat your veg. I once left a doctor's appointment to be asked by the secretary absentmindedly “And how did you get on?” as she printed out my receipt, “Oh, 6 months” I said with a chirp. She dropped the receipt as her eyes grew to the size of basketballs “6 months…to live?” she whispered as she fell into her seat, “6 months to my next appointment” I reassured her, checking my pulse on my way out, for my own surety.


I can appreciate that getting a medical card when you are terminally ill must be a welcomed relief but I doubt many patients have that ‘Yes! Hah, In your face!’ moment of victory. I would suggest that true compassion would be to give medical cards to the pre-terminally ill (I accept that describes us all, I stopped short of suggesting the cards go to all ‘undead’). However, I am referring to the patients with a significant illness that comes at a great cost, both financially and otherwise, who will likely live beyond the 2 year cut off. Their suffering is real, can’t we take the load off them somewhat. Many young patients that experience heart failure will live longer than 2 years (for my own sake, I certainly hope so!), but the quality of life is never the same again. 


I talked to Esther Barry on the Irish Heart Foundation Heart Failure patient panel who is a young mother living with an inherited condition, “We are a new generation living with heart failure. Many of us no longer work because of our disease, yet we must worry about not only surviving this, but how can we financially live with it.”


There are also more straightforward reasons to link heart failure into the medical card program. The Department of Health, HSE and the Irish Medical Organisation are working on a system-wide reform that hopes to shift chronic disease management from acute settings to the community (including heart failure). The reform’s main shortcoming is that it only serves people who have a medical card. Heart failure does not guarantee you a medical card, so the hero-maker moment falls flat. I wonder if there is a course the government could take in joined-up thinking, I suppose, let them work on their joined-up writing first. 

My expectations are low, the government will argue they do not have open coffers to sponsor every plight. Heart failure patients already saw our base worth nailed low to the mast when we were relegated to cohort 7 during the recent Covid vaccine priorisation. However, 21 billion was allocated to health and social care in the last budget, the biggest ever investment in Ireland’s health and social care services. The estimated cost of heart failure, from a report conducted in 2015, costs in the region of 660 million - so that’s about 3%. Given the older generation make up most of the heart failure patients and may already have a medical card, we’re possibly arguing about 1% here. There are bigger spends out there, 5.5% will be spent on mental health for example, and rightly so. But this shouldn’t even be about money, it should be about looking after people with long term chronic serious illnesses who rely on daily medications and support to stay alive. 

To be truly fair, discretionary medical cards could be allocated on a basis of diagnosis. The alternative is to gorge ourselves on Wonka bars in the hope of finding that golden ticket.