AFTER 20 years there is light. It has been 20 years since Labor introduced Medibank (now Medicare). The 20 years have been consumed by bitter ideological warfare over the provision of health care in Australia. The doctors and the Coalition on one side fought against the Labor Party on the other. Patients were in the confused middle.
This week saw a truce. Now two white flags have gone up and, with any luck, the people of Australia can see some constructive talking between the medical profession and the Government to improve Australia’s health system.
The white flags, indicating peace rather than surrender, came in the form of Senator Graham Richardson taking over the Health Ministry and the election of Dr Brendan Nelson as president of the AMA, succeeding Dr Bruce Shepherd.
Richardson came out after a month’s enforced post-election silence with an admission that all was not well with Medicare, especially hospital queues, and he would talk with the profession to find ways of fixing it.
Dr Nelson upon his election on Sunday said the profession wanted to talk in good faith and that this was shown by a motion by its national conference that the AMA would cooperate with the Government in overcoming the difficulties with Medicare.
It was as if the PLO had acknowledged Israel’s right to exist and that Israel had recognised the PLO as a representative of the Palestinian people.
The AMA, in effect, has accepted Medicare’s legitimacy. The Government has acknowledged that the nation’s health care cannot be provided by Medicare alone. It may not sound like an all-points peace plan, but it is a huge breakthrough when one considers the political history of public-health insurance in Australia and its sad fall-out on the sick people of the nation. Remember the idiocies of the Fraser Government chiselling away at Medibank, piece by confusing piece? Remember the dogged Brian Howe determined not to acknowledge that the public system could not do it alone?
So what are the issues? Hospital waiting lists and over-servicing seem to be Medicare’s big weaknesses. And Senator Richardson has at least partly acknowledged that. He has sought a better, system and reduced queues, but different states count it differently. Someone can be on the queue even though they have voluntarily postponed, for personal or work reasons, or even if their doctor has suggested a postponement.
There are empty beds in private hospitals and not enough in public hospitals. Senator Richardson, however, has all but abandoned the Government’s plan to buy private beds and will spend the ear-marked $100 million another way.
The private profession says the best way to fill the private beds is to encourage more private health insurance. Senator Richardson acknowledges it is not equitable for wealthy people to occupy public beds and that there is a useful role for private insurance.
The initial trouble was that Medicare was too good for its own good. Young, fit and healthy people who paid the levy did not see the necessity for insurance, especially those who left the parental home after 1983. Medicare insured them against catastrophic injury or disease and given that the big public hospitals treat the major conditions best, why bother with private insurance?
So the fit left private insurance. When they left, premiums went up, driving even more away. In the past 10 years the privately insured have fallen from 70 per cent in 1983 to 48 per cent now.
The executive director of the Australian Private Hospital Association, Dr Greg Herring, argued at a recent conference in Canberra that cost was the single biggest reason for people opting out. He pointed to a survey saying that 53 per cent of those who don’t have, but would like, it cited cost as the reason. He blamed most of the increased cost of premiums on government policy.
He acknowledged Medicare’s strength in treating emergencies and said, “”If you’re going to get sick, Australia is still the best place in the world to get sick in.”
He argued for a mixed system, but warned that the mix was becoming too lop-sided. Many people under-estimated the role of the private sector. Fifty-three per cent of admissions and 57 per cent of bed days were private (3.6 million bed days of privately insured patients in public hospitals and 5.5 million in private hospitals).
He warned that if we were in strife now with the private sector taking up that much of the burden, things could go downhill fast unless the leak from private insurance was stemmed.
Dr Herring’s argument (and it is certainly not a new red one) is that people over-estimate what Medicare does and wrongly assume that there is only a small amount of private health care to be mopped up which would not make much difference. Without the private sector, he argues, Australia’s health system would be in real strife.
Too many people were relying on Medicare, he said. In 1983 it was 5.9 million: in 1992 it had risen to 11.8 million. A lot of that was due to increased population as well as people dropping insurance.
But private insurance is not the only factor. The Commonwealth has cut its contribution to total hospital funding from 42 per cent in 1975 to 34 per cent now.
The ageing population is also causing bigger demands.
At the same conference, Dr Chris Rigby, executive director of the Australian Catholic Health Care Association, said the waiting lists were more to do with the ageing population and new technology than people not taking private insurance.
Merely subsidising private insurance would not solve the problem. Like the wool subsidy, that would only postpone reform. He thought the private hospitals had to get more competitive and had to bid for large clients. The private funds, in turn, should look more closely at containing health costs.
Senator Richardson, too, thinks that there are more causes for the waiting lists than declining insurance. Lack of some specialists in some provincial centres is another reason.break The equity argument put by Dr Nelson and Dr Herring is that under the present system people on $25,000 with private insurance are subsiding those on $70,000 without it. Those on $25,000 might feel it necessary to take insurance because they are in a risk group for so-called “”elective” surgery, such as like hip and knee replacement or sports injury; whereas some on $70,000 are young and fit and know their call on the health system is likely to be for emergency or serious illness, which Medicare is coping with well.
The Whitlam equity of the 1970s free care for everyone simply cannot be afforded. Moreover, without a significant private element, there would be little or no competition, leading to inefficiency. Just as without a safety net and significant public element, costs will rage out of control, as in the US.
Now that both sides in this debate seem to have recognised this, the debate about how to get the mix right and how to improve the health service can mature a little. Head-to-head brawls usually produce only simple solutions. In health, of course, the problems are invariably complex and linked to many factors.
It may well be that under the new truce, the profession and the Government can look at ways to encourage more private insurance beyond tax-deductibility and means-testing Medicare the two most cited panaceas.
Certainly, the ridiculous position should change whereby private patients in a public-hospital bed have to pay bills that the Medicare patient does not; that is an incentive not to insure.
The nature and type of insurance needs looking at. Is community rating (under which all pay the same principal) appropriate for self-inflicted illness caused by smoking and obesity? If the young pay more to insure their cars because they are more likely to prang them, why shouldn’t they pay less for health insurance because they are less likely to get sick?Is bulk-billing combined with too many GPs in the cities causing an incentive to over-servicing?
THE NEW truce might also enable some of the social and preventive measures dear to Dr Nelson’s heart to be put higher on the Government’s agenda.
As the amount of money for health shrinks in the face of the $16 billion government deficit and as technology, population increases and ageing absorb even more of the money that is not there, the community inevitably faces more rationing. It is unlikely that changing the private-public mix will alone overcome the whole problem.
The total funding provided by Medicare and private insurance does not anywhere near cover total health costs.
The mention of rationing is not alarmist. We have it now. Some people miss out. They die before they get the treatment or they do not get Medicare for certain sorts of treatment. Perhaps the way the rationing is done should be a little more deliberate.
It may well be that Australia looks at rationing schemes like the Oregon experiment, where the people vote for a priority listing of medical conditions from one to, say, 350 and the public system provides no money for items below a cut-off point according to what funds are available. Below that you have to insure or pay for yourself.
In Oregon, the people, sensibly, put the common cold well down the list as they did for the treatment of lung cancer, liver transplants and IV fertilisation. It may sound brutal, but it is a democratic ordering of priorities and no better nor worse than the present system of people dying of heart disease on the waiting list, or being denied Medicare for physiotherapy which is such an essential part of getting back to productive life.
The essential point about movements in the health arena over the past month is that we can expect more constructive imagination and less destructive ideology. It’s been 20 years in the coming.