Health policy
A step towards restoring universality
Former Health Department head Stephen Duckett, writing in The Conversation, explains the government’s promise to raise GP bulk billing, and the opposition’s response.
The changes are designed to make bulk billing attractive again. In 2014 then Health Minister Peter Dutton attempted to introduce a compulsory payment for GP services. When the Senate knocked it back the government decided it could achieve the same end, slowly, by freezing the Medicare rebate for GP services, extending a temporary measure that had been introduced by the Gllard government. The rebate was no longer to be indexed to indicators of inflation or to practice costs. For example the MBS fee for Item 23, a standard consultation, was frozen at $37.05. The freeze was lifted in 2019, but it was not backdated. It is now $42.85, but if it had not been frozen it would now be $50.00.
That’s the standard rebate. There is also an extra payment to medical practitioners for consultations they bulk-bill, but this is restricted to services for people in specific categories – children and recipients of concessionary health care cards.
The changes explained
Duckett explains that under the government’s proposed changes, the $42.85 standard rebate stays, but there is to be a significant increase in the extra payment for bulk-billed services. In cities bulk-billed services will be paid $61.83, and the payment will be higher in remote regions.
Importantly, there is an additional 12.5 percent practice payment for practices that bulk-bill all their services, bringing the fee for a standard consultation up to $69.56.
The incentives are strong. Bulk-billing is an assured payment system, doing away with the costs of billing individual patients. (When Medibank was introduced, in recognition of this benefit, the bulk-billed rebate was actually lower than the scheduled fee.) And a higher payment means that medical practitioners who bulk-bill some of their patients, particularly those who at present are not eligible for the extra rebates, don’t have to cross-subsidize those services by charging higher fees to others.
A return to universality
The significant aspect of the changes is that they are a return to the principle of universality, the original principle of Medicare and its predecessor Medibank. The payments are no longer compensation for bulk-billing; they are a strong incentive for practices to bulk-bill.
For at least the last eighty years, there has been an ideological division between Labor and Coalition governments. Labor’s policies have been driven by a principle of universalism: in its purest form health care should be free for everyone, funded by progressive taxation. The Coalition has seen public support for health care in terms of distributive welfare: ideally people should pay for their own care, or should use private insurance to share their costs, and subsidized or free services should be only for the indigent.
Neither party has been able to implement its policy fully. For example, from the outset, dental services were excluded from Medibank/Medicare. Successive Coalition governments, bound by vague election promises to keep Medicare, reluctantly retained elements of universality. Labor, in office from 1983 to 1986, allowed universality to be sacrificed to fiscal constraints: over that time it failed to eliminate private health insurance, which remains as the main element of an inefficient and inequitable two-tier health system.
Martyn Goddard, in his Policy Post, has a full analysis of the government’s bulk-billing proposals, with a history of the way policies, guided by contrasting partisan ideologies, fiscal constraints, and public support for Medicare, have moved between universality and support for the indigent.
No doubt many will see the government’s proposed changes in the context of an election contested on cost-of-living issues, and they will certainly help in that regard, but they are much more significant than that.
As Duckett says, “Australia will now rejoin all other high-income countries (other than the United States) in having health funding underpinned by universality”. Duckett believes the measures would achieve about 90 percent bulk-billing for GP services, while Martyn Goddard is a little more sceptical about their reach.
Politically the Coalition had to respond with a look-alike promise, but it would be an extraordinary shift in ideology if it were to drop its long-held opposition to universality. Duckett explains how the politics will play out:
The Coalition obviously hopes to negate the impact of a popular announcement by matching it. What will weigh in voters’ minds, though, is whether today’s Coalition announcement will be delivered after the election. The Coalition has a long history – dating back to Malcolm Fraser – of promising one thing about health policy before an election and reversing it after the vote, and this will probably fuel a “Mediscare” campaign by Labor.
Laura Tingle has a 6-minute clip from the 730 program, explaining the policy and its politics. The Coalition, and Dutton in particular as former health minister, lacks credibility because it has broken past promises it has made on health care. It is easy to keep a promise to keep one aspect of Medicare, while stripping money out of other health services, as the Coalition has done in the past. Dutton’s promise to fund the Coalition’s plan with cuts to the public service lacks credibility. (Abul Rizvi, writing in Pearls and Irritations, explains how Dutton’s public service cuts would work, resulting in some combination of higher-cost privatized services and longer waiting times for services that remain as government responsibilities.)
The longer term – it’s only a first step
This reform is probably as far as a government facing re-election can go. It goes some way to restoring universality, and will be welcomed by those whose use of health care is limited to GPs and pharmacies, which covers most Australians most of the time. Some health care commentators note that payments for health care are still built around a fee-for-service model, which isn’t the best way to provide care to those with chronic conditions. And these changes still don’t bring Australia any closer to having an integrated health care system – our messy set of separate funding and delivery services will still have to muddle along.
It is only one step towards universality. There is a long way to go in terms of access to specialists, and over its most recent periods in office Labor has lacked the political courage to rid Australia of private health insurance and to bring private hospitals in to the same funding stream as public hospitals. These problems are presently manifest in disputes between private insurers and private hospitals over maternity services.
Those are the areas where the big money lies, ready to fight back at moves to reform health care.
Road fatalities – still some way to go
Our roads have become much safer over the 80 years since car ownership became widespread. Last year’s 1300 deaths still commanded media attention, but had our road fatality stayed at its level in the 1950s, there would have been about 5000 deaths last year.
Seat belts, improved roads, better car design, tougher licensing standards, strict limits on alcohol consumption, bicycle helmets, and public awareness campaigns have all contributed to this achievement. Some of this has been by government regulation, some by public investment, and some by the market: even the most devote disciple of the “small government” cult would have to admit that this is a story of successful public policy.
But as shown on the graph below, plotted from BITRE data, fatalities have stopped falling in recent years, and they seem to be rising.
Public health experts would be familiar with this phenomenon. As the big gains are made, the remaining cases stem from a large variety of causes, and underlying patterns are hard to detect.
Ali Soltani of Flinders University writes in The Conversation that Australia wants zero road deaths by 2050 – but there’s a major hurdle. In fact he found several hurdles, but he lists six ways they can be overcome through public policy measures, generally more targeted than earlier successful interventions. Open Forum has a summary of the work of Soltani and his colleagues, with references to groups at risk – motorcyclists and older drivers – and to regional differences in road fatalities.
Smoking is even worse for our health than we had thought
We don’t need to be convinced that smoking is bad for our health, but we may be inclined to believe that there is some linear relation between the number of cigarettes we smoke and our risk of dying of chronic lung disease or lung cancer: maybe one or two cigarettes a day won’t do much harm.
That’s not so, according to a study by ANU researchers published in BMC Medicine, and summarized in an article in ANU Reporter: Australia’s biggest killer: smoking causes 66 deaths every day and 24,000 a year. Your first cigarette lays down a carcinogenic layer on your lungs: that’s where the damage starts, explains lead researcher Emily Banks on Radio National: Smoking death rate higher than once thought. (7 minutes)
Policymakers should take note. Increases in tobacco excise have raised the price of a 20-pack of cigarettes to $40 – $50 – a policy that makes sense provided the smuggling trade can be intercepted. But to the extent that there is some price elasticity in the demand for cigarettes, high prices alone probably result in people cutting back on smoking, rather than quitting. If the health consequences are non-linear, as the study suggests, excise may have limited effectiveness as a public health measure.
Remembering Covid-19
North Head Quarantine Station opened 1832
Older Australians may have had grandparents who told them about the 1918-19 Spanish influenza. There are still many Australians who remember the polio epidemics of the 1950s and 1960s. But such memories fade quickly, and we all seem to have “moved on” from the Covid-19 pandemic, although there are still about 450 Australians dying every month, of or with Covid-19. It will fade away but never go away
The ABC News Story Lab has put together a document about how Covid-19 affected Australia: It has been five years since COVID-19 hit Australia. These numbers show its impact. People living in Melbourne spent, in total, 262 days in lockdown. Woolworths sold 21 million rolls of toilet paper in one week of panic buying. Working from home became much more commonplace.
It’s something worth preserving for grandchildren, in whatever medium will have durability. Some of them may become politicians, or may find work in public health – if we remember to sustain investment in public health, which is always at the end of the queue for public funding.