The recent death of Bill Hayden is cause for contemplation of his most significant legacy to this country.
As social security minister in the Whitlam government, Hayden worked with two young health economists, John Deeble and Dick Scotton, to develop Medibank. He battled the Australian Medical Association, private hospitals, private health insurance funds, the non-Labor states and the Coalition-controlled Senate to do so. It was Australia’s first universal healthcare program, providing access to hospital and primary healthcare for all of the population.
Medibank was closed down by the Fraser government but revived as Medicare in 1984 by then-prime minister Bob Hawke and his health minister Neil Blewett. It has become embedded as the underpinning of Australia’s health system, and despite repeated attempts to undermine it by conservative governments, retains popular status for the Australian community.
As part of negotiations to establish Medicare, the states agreed to make access to hospital care free in exchange for a Commonwealth commitment to meet 50% of the reasonable cost. That commitment has eroded over time. Former prime minister Kevin Rudd negotiated to guarantee 40% of hospital costs as part of his hospital and healthcare reform agenda, but even that was abandoned by the Abbott government.
It is in primary healthcare, however, that most of the pressure on Medicare has been felt.
Universal access to healthcare requires that it be available for everyone, irrespective of their financial means. This is no longer the case, as real bulk-billing rates have collapsed and fees to see a general practitioner have risen. People with easily treatable conditions are discouraged from seeking healthcare by cost and find their way, much sicker, to hospital emergency departments. Emergency departments are being swamped by avoidable presentations — either people who should be attending a GP or who would not require emergency treatment had they done so.
Initiatives to address the crisis such as urgent care centres help, but they do not address the problem at source. The most recent changes Introduced by the Commonwealth government to support bulk-billing increase the subsidy for bulk-billing. They are welcome, but unlikely to be effective. Carrots without sticks are seldom effective in bringing about changes in institutional behaviour
The current crisis in primary healthcare is a result of intentional behaviour by conservative governments to undermine and ultimately destroy Medicare. The combination of freezing Medicare rebates and deregulating doctors’ fees have had the predictable result of making bulk-billing unsustainable for providers and putting primary healthcare beyond people of modest means.
There is an alternative and one that would have appealed to Hayden: reset the Medicare rebate at a level that gives GPs a reasonable and sustainable income and index this. Then cap the fees that GPs can charge at the new rebate level. While we are at it, we should cap specialist consulting fees that are out of control.
There would be a hit to the budget but the economic impact and ultimate fiscal impact of improving access to primary care and reducing demand on expensive emergency care would be very significant. Opponents will claim that this is “conscription of doctors” and so unconstitutional, a claim that is made any time there is an attempt to properly manage healthcare, but it is a claim that has never been tested in court. If the claim was successful, it could be worked around.
I see few alternatives that might restore Hayden’s vision of Medicare as truly universal healthcare.
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To offset that increase they could cut the Private Health Rebate.
Prescriptions for long term medications should be able to be renewed by pharmacists, rather than having to see a GP 2 or 3 times a year.
Eliminate Howard’s terrible PHR.
Eliminate every aspect of Howard’s foul legacy.
This!
Good ideas Tom, but we need to find hundreds of billions of dollars to buy nuclear powered submarines for which no creditable need has ever been demonstrated. I’m sorry, but the money for that has to come from somewhere, and given we are going to cut taxes as well, it means health care, aged care, education, social services etc will just have to make do with a lot less.
Bulk billing is not a right. It was always intended to be an optional extra. The ACTUAL model is that Medicare pays 85% of the scheduled fee to the patient as a rebate because (for constitutional reasons) Medicare, like Medibank before it, is actually universal health insurance, not universal health care. Bulk billing was an optional extra, never intended to be universal, and made attractive to doctors as a way of reducing billing costs and bad debts. It is not longer attractive or even sustainable as it isn’t even close to the true cost of providing the service.
And doctors fees are not capped for the same reason that dentist fees, accountants fees, lawyers fees, vets fees, and even your electricians fees aren’t capped. We have a system where people are free to charge what they feel they are worth. Or in many cases what they think the market will sustain. Cap fees and the people smart enough to do medicine will quickly work out they are far better off doing law instead, given that lawyers, being the larval form of politicians, are probably the least likely profession to find themselves subject to government fee control.
An ageing population and vastly enhanced medical technology imply an increase in the Medicare levy to sustain a higher scheduled fee. Unfortunately, the income taxation base for collecting premiums for universal health insurance in Australia was eroded by reckless concessions to older taxpayers in the Howard-Costello era. This is also the group making most demands on the health system.
Indeed, that and the protracted freeze on rebate increases, for GPs and some specialist groups, which was needed to pay for this largesse to the older cohort who in many instances have actually been completely excised from the corpus of taxpayers along with multinational corporations. But the Medicare levy has never paid the full cost of Medicare, it was always meant to draw to some extent on consolidated revenue.
So what do you suggest Alastair? Bumping off anyone over the age of 60, 65, 70 to alleviate the problems supposedly caused by “the group making most demands on the health system”?
Have you spent any time in Emergency department waiting rooms with a child or grandchild suffering concussion and throwing up into vomit bags (for 3, 4 hours) provided by a nurse while others in the 20-40 age group are seen first because of “mental disorders” but later described as “junkies ” by treating professionals when the child is finally seen? I have!
Have you watched your elderly mother lie on an ambulance stretcher in a hallway for 6 hours with a broken hip, without any form of pain relief, let alone a mouthful of water (because they knew she’d need surgery) in a major hospital while others were taken in to see a doctor (walking in, I might add and chatting as though they were fine and dandy) – all because she refused to “scream out in pain so that we HAVE to get a doctor to see you” (the words of the nursing staff as well as a few passing doctors ) ? I have!
Just three examples I can cite of a dozen or more instances where “older” people haven’t been the ones to clog up the “hospital system” in emergency departments.
Yes, some older people may be to blame but ask any Nurse or doctor working in these hospitals and the majority will tell you who the real culprits are.
And one more thing Alastair, you will be old one day too – it happens to most of us if we are lucky.
Bill was the last of the true Labor politicians?
He would scrape the current swill despoiling the party name off his shoe.
I am old already. That old that I remember the debates over the original Medibank and even knew some of the major participants. You completely missed my point which was that an ageing population, and vastly improved ways of keeping them healthy means greater costs that somehow have to be financed. Universal health care now requires higher levies than originally envisaged, made more difficult because of the narrowing of the taxation base by unreasonable concessions to the older cohort, among many anomalies in the Australian taxation system.
I think you missed Alistair’s point that we are not spending enough on the increasingly costly health care system, in part because most retirees have been excused from paying tax. He’s right. My retirement income is higher than my son’s working income, yet I pay less tax than he does, plus get perks like free public transport and all Pension concessions. And I’m not one of the richest 20% of retirees, the self-funded retirees, who complain the most, even though most of them don’t pay any tax either.
I wish Australia allowed public access to tax details as allowed in some countries. It would be useful to actually know who pays what. I am a self-funded retiree very definitely still in the tax system and very definitely excluded from the misnamed “age” pension. I agree excluding over 60s super income from tax was a very poor decision ie a Howard decision.
Exactly, the boomers protected species politically and benefit from the can being kicked down the road (& blame ‘immigrants*’); the ALP govt ’80-90s could see future demographics and more tugging on budgets, hence, superannuation, but LNP follows the imported US ‘libertarian free market’ of IPA etc. (the US has most expensive health system in the world but nowhere near the best overall)
While cutting the taxes & base, stresses budgets or leads to cuts of services etc. which if one looks at the US is deeply ideological; see Thomas Franks ‘The Wrecking Crew’.
*The real game on the economy, taxes, property etc. is the boomers vs. millennials; the latter are outnumbered by the former who are catered to.
The Boomers (59-77yo) are massively outnumbered by those 18-59 (~5.4m vs about 13m). Indeed, even restricting to just Millennials (and there’s no reason to actually do this in the context you have given, other than to suit a very specific statement), they are basically even (both ~21.5% of the population).
https://www.theguardian.com/australia-news/2022/jun/28/australias-millennial-generation-is-overtaking-baby-boomers-new-census-data-shows
“Defined as the generation of people born between 1946 and 1964, the number of baby boomers fell from 25.4% to 21.5% of the overall population. Millennials, born between 1981 and 1996, increased from 20.4% to 21.5%.”
Data analysis? Invalid, comparing apples with oranges and ‘flooding the zone’ with non sequiturs, masquerading as analysis, to avoid specific testing.
For example the younger half of millennials are padded out with temporary residents eg. PG students & backpacker churn (who will not be around in future), while boomers are almost entirely citizens and PRs; at time of Covid census many temporaries were in Oz from before e.g. bridging visa due to slow processing.
Another test, which you have avoided, how do you explain the ever increasing old age dependency ratios if as you claim millennials etc make are so significant?
Running protection for older generations on their tax breaks and need to vote LNP….
Just the usual vapid bluster from you.
Per the AEC, there are a total of 5.7m registered voters aged 50+, out of 17.7m total.
5.8m voters aged between 25 and 44.
1.7m aged 18-24.
https://www.aec.gov.au/enrolling_to_vote/enrolment_stats/elector_count/index.htm
Another test, which you have avoided, how do you explain the ever increasing old age dependency ratios if as you claim millennials etc make are so significant?
I’ve never avoided it. I’ve stated it’s a meaningless number to quote in and of itself, and pointed out that the actual dependency ratio of workers to non-workers, has been higher only a couple of generations ago.
Yes, yes you do. All the time. Your obsession with income tax and the working age population is a regular reminder of it.
*aged 60+.
Sorry. Bulk billing (at least for primary care) was very much the intention of the original Medibank, the principle being that it was much cheaper to encourage poor people with kids, indigenous Australians, etc to see their GP to nip developing health problems in the bud rather than wait until the condition required hospitalisation (where most of the health system’s costs are generated) because they couldn’t afford to see their GP. This principle is ignored by idiots like Abbott and co who argue for co-payments so people don’t ‘abuse the system’. The only people who are likely to abuse the system are hypochondriacs; and they will see their GP unnecessarily regardless of co-payment.
The reimbursement was set at 85% because general practices lost about 15% on bad debts (mostly people who couldn’t afford to pay the doctor) and billing administration.
These are different issues from the failure of governments to maintain the scheduled fee and whether fee-for-service is still the best model for our health system.
What you say is the actual truth of intention of bulk-billing. I think the common misunderstanding of history of australian universal healthcare is due to most people not remembering healthcare (or being alive) before Medibank/Medicare.
Medibank/Medicare has been positive for the transformation of healthcare in Australia. With a comparatively small population and large land mass, we used to be a bit second rate compared to US and UK. We now have public hospitals that are comparable with world centres of excellence. And health providers who are leaders in their field.
Since Whitlam, there has been a long-running campaign to dismantle universal healthcare and follow the USA profit-driven commodification of healthcare.
Primary care has been very disadvantaged by the warfare started during Health Minister Abbott’s rule. We ALL benefit when the best and brightest are also attracted to general practice. Income differences between specialists and GPs used to be less, so specialising is probably now more income attractive. I suspect coalition health ministers secretly think GPs are the dunces of medical school.
I worked in a public hospital when Fraser dismantled the original Medibank, when eligibility for free public hospital care was restricted to welfare recipients with income below certain limits. The eligibility criteria were complex and often misunderstood, with many people confused about whether they were entitled to free public hospital care, or whether they were not entitled and would receive a massive bill. I saw elderly people sued for their life savings because of such confusion. It was truly heart-breaking.
Thank you Tom. My rheumatologist has just put up their ordinary consult cost to $190 and their initial consult cost to, wait for it, $580. A consult last week cost $190 for a rebate of $71.70, leaving me $118.30 out of pocket and I’ll be $118.30 short for each future consult. Instructively, while the specialist is charging $190, the MBS set fee for the consult (using the MBS item given on the receipt) is $84.35. The rebate of $71.70 is based on that MBS fee (85% of it). Now some might argue that a doctor setting their fees 124% higher than the MBS fee is taking the urine sample. But I couldn’t get a plumber out for a blocked sink for much less than $190. If I tried to convince one to accept $71.70 or $84.35 for the job, I’d be up to my armpits in greasy overflow water before you could say “Where’s the bloody plug”. The Schedule fees are wildly out of kilter with the true and/or fair costs of providing medical consultations/treatments and need a complete overhaul. Yes, it’d deliver a whack to the budget but the whole system has been badly neglected for far too long. We’ve all been paying the levy for a long time and all we’ve got for it are widening gaps. $190 might be beyond the MBS pale but a schedule fee of $150 isn’t and that would almost halve the gap in this instance from $118 to $62 …
The plumber comes to your house, and has to maintain a stock of materials; be should probably be charging double what you pay for a visit to a specialist.
My mother and I have similar eye issues that require the same treatment (regular eye injections).
She is a pensioner and gets a discount.
I have no concessions.
Yet her doctor charges nearly twice as much as mine.
That doesn’t seem right to me.
(I think she gets more back from Medicare, but that’s because she is a pensioner, not because of the fee charged.)
And you will find the same if you both went to different lawyers, to different accountants, to different dentists, had different plumbers come to unblock your loo, or took your dog to different vets. Professionals of any description are free to charge what they wish.
This sad situation is a reminder of the fake outrage Turnbull ran after the near-death experience of the 2019 election narrowwin: his outraged claim that the attack on LNP plans to privatise Medicare was a lie. this was pursued big time by News Corp columnists. of course the LNP did plan to privatise Medicare by freezing rebates and forcing doctors to charge a co-payment leading to a situation where it is difficult to find a bulk-billing doctor. Note how “pensioners” (and that is a scheme designed to be rorted by the affluent) and any child (no matter how wealthy their parents) are bulk billed. Self-funded retirees , no matter how old are not necessarliy bulk-billed.