The Howard vision for Medicare
Medicare, as most Australians understand it and the services it provides, is an overwhelmingly popular healthcare system. Even the Liberals have been forced to pay lip service to it and as recently as last week Federal Health Minister Tony Abbott had the following to say: "This Government believes in Medicare. Medicare is an article of faith. We will strengthen and protect Medicare. And we are prepared to invest in a stronger Medicare system." He was speaking in support of his latest tilt at "reforming" Medicare after the defeat of the "Fairer Medicare" package unveiled last April. Nobody ought to be fooled by the Minister's public declaration of faith in Medicare. More sincere and more passionate was John Howard's outburst to Sydney radio personality John Laws in 1987 about what he would do in government: "The second thing we'll do is get rid of the bulk-billing system, it's an absolute rort. We will be proposing change to Medicare which amounts to its de-facto dismantling. we'll pull it right apart. Bulk-billing will be abolished, except for people such as pensioners who really need it." Medicare was an "unmitigated disaster", "a human nightmare", "a financial monster", "an administrative quagmire", "a scandal" and a "miserable cruel fraud", according to the would-be Prime Minister. In spite of the weasel words now used to praise Medicare, the introduction of "Medicare Plus" would be a giant step toward achieving the Howard vision of its de-facto dismantling, the establishment of an essentially private health care system with a safety net for the "deserving poor". Smashing the bulk-billing pillar With the promotion of this latest package, the Federal Government has taken double-speak to new levels. On behalf of all Australians, Tony Abbott has concluded that bulk-billing "is not the essence of Medicare". He would remove it as one of the pillars of the system — where it once stood alongside free treatment in public hospitals and affordable medicines through the Pharmaceutical Benefits Scheme. Consistent with this downplaying of the importance of bulk- billing, "Medicare Plus" contains no serious measures to reverse the decline in bulk-billing rates. These have slid from 80.6 per cent of doctors bulk-billing in 1996 to just 67.4 per cent at present. The package proposes an increase of $5 in the Medicare rebate paid to GPs when they bulk-bill a Commonwealth concession card holder or child under the age of 16. There is no $5 extra for bulk-billing other patients. As Doctors' Reform Society President Dr Tim Woodruff points out: "General practitioners charge an average of $13.64 co-payment now if they don't bulk-bill patients. Medicare Plus offers them $5. Why would they change?" Mr Howard says he is confident they will. "Five dollars will add $15,000 to $20,000 to the income of the average GP in one stroke", he told the media last week while failing to add how much co-payments of anything up to $100 (or more for specialists) would add to the bank balance. No shortage of money "We do not intend to introduce any kind of means-testing for bulk-billing, none whatsoever", Howard told Parliament in March. Eight months later there is a proposal for bulk-billing from which only concession card holders (who live in poverty) and children under 16 (who usually do not have independent means) might benefit. Using the hair-splitting semantics favoured by the Government, the PM has not directly violated his previous undertaking. Doctors could accept the present Medicare rebate and charge other patients no additional amount at all. The reality is that few could meet their overheads and remain in business with such an approach. Ignoring the trifling 65 cent increase in the rebate at the beginning of this month, the amount reimbursed by the Commonwealth has been stuck at around $25 for over a decade. Some estimates have it that the Medicare rebate for a standard consultation is only 62 per cent of the value it ought to be when inflation is considered. Most commentators say that to operate in the way it once did to support bulk-billing, the rebate should be between $40 and $50. The AMA estimates that an increase of the rebate to more workable $35 would cost a hefty $500 million a year. Of course, this option would not even be considered by a government of the current ideological stripe, $7.5 billion surplus or no $7.5 billion surplus. Nor is it prepared to reduce its $16 billion (and rising daily) military budget — which ironically and tragically will cost lives and harm Australia. Far more likely are tax cuts and other election year sweeteners for the wealthy. The Federal Government is immune to arguments about the Medicare rebate and its relationship to declining bulk-billing rates. In fact, Tony Abbott prefers to blame all sorts of other weird and wonderful causes and to play down the rebate issue. In a speech made last week — available on his website under the title Bulk Billing was never for everyone — he offers some alternative and highly original reasons: "Since 1999, the percentage of visits to the doctor which are bulk-billed has fallen from just under 80 to just under 70 per cent. This is partly because there are fewer doctors per head of population and thus less competition, partly because the Medicare rebate has not kept up (doctors argue) with medical inflation but mostly because many doctors think that 'free medicine' is unprofessional." Using the Health Minister's logic, the biggest problem is that more and more doctors are deciding to get a bit more "professional". "Safety nets" and "universality" The Health Minister would also have us believe that he is offended by "welfare" being paid to those who don't need it. "I don't think you or I or Kerry Packer or John Howard ought to be able to roll into the local medical practice and demand to be bulk-billed", he told ABC's Lateline last week. (It should be noted that Howard does not object to wealthy people putting their hands out for a $14,000 first homebuyer's grant or having 30 per cent of their ridiculously expensive private health insurance paid through the government's Private Health Insurance Rebate scheme.) Bulk billing for everyone is important — universal access to affordable primary care is very cost effective for (and beneficial to the health of) the individual (rich or poor) and the community. It is also a public health issue. If the likes of Howard and Packer relied on the public system (as did Packer in a life-threatening emergency) along with everyone else, that would be a virtual guarantee of a high quality system. And if Packer and his mates paid their taxes, then financially we would be way ahead. The Private Health Insurance Rebate scheme and other subsidies to the private health insurance industry cost around $3.6 billion every year — more than enough money to sustain universal bulk- billing and eliminate public hospital waiting lists and provide a public dental scheme. Bulk-billing for all not only offers the prospect of better quality services, but keeps the overall cost down. If the principle of bulk billing being available to all was abandoned, then the community would lose control over doctor's fees. The Government cannot regulate doctor's fees directly because of the Australian Constitution, but it can through bulk-billing, as it does for medications through the Pharmaceutical Benefits Scheme. In these areas at least, Mr Abbott sticks to the generally understood definition of the concept of "universality" where it ultimately helps to put money in pockets of big businesses like the private hospital corporations and insurance companies. When it comes to Medicare, a new definition of "universality" is trotted out. "Medicare is a universal health insurance scheme to ensure that no one faces unaffordable out-of-pocket expenses because of ill health." Of course, the meaning of the term "unaffordable" will be left in the hands of those guardians of word definitions that advise the Health Minister. But, more importantly, the Minister omits to mention that no one would face "unaffordable out-of-pocket expenses because of ill health" if everyone was bulk-billed. This would be by far the best and cheapest solution. Even within this new definition of "universality", the new Medicare-destroying program proposes different treatment for different categories of people. As mentioned before, Commonwealth concession card holders and children under 16 years might be bulk-billed and have no further out-of-pocket expenses from their visit to the GP as a result of the $5 bonus paid to doctors. For members of families that currently receive Family Tax Benefit (A), a refund of 80 per cent of out-of-pocket expenses would be paid once they total more than $500. For all other individuals and families, the refund is paid once those expenses exceed $1000. To the Minister $500 or $1000 may not sound a great deal. But to many working people, unemployed, retirees and students it is a great deal of money, especially when considered along with dental bills, the price of medicines (a safety net of over $600), hearing aids, glasses, and other health needs. And, there are no guarantees as to how big the safety net will remain in the future. Mr Abbott has confounded commentators by introducing a three-tier health system, rather than a two-tier one! Clearly, bulk-billing rates will not be improved by the current measures and very few Australians will benefit from the "safety nets" installed with "Medicare Plus" given present costs. Queue jumping in doctor's surgery These people may be bulk billed but they will become second class citizens as far as the health system is concerned. "Private", fee-paying patients will be given 20 or 30-minute appointments, or even longer ones. Bulk-billed patients will wait to the end of the queue and/or get only half as much time as paying patients. Yet any doctor can tell you that it is the elderly and paediatric patients who are more likely to need twice as much time as the other patients. Already some surgeries are doing this, with special times are set aside for bulk-billed patients who sit around for hours waiting their turn and then being rushed through when it comes. In effect, having introduced "hospital queue jumping" with the 30 percent Private Health Insurance rebate, the scene is being set for queue jumping in the doctor's surgery!! Inevitably, greater numbers of people will present in the hard- pressed emergency departments of public hospitals. Newspoll research conducted for the Health Services Union shows that nine per cent of Australians — or 1.2 million people — will opt to go to emergency departments if their doctors put up their fees or stop bulk-billing. The latest measures will not fix this problem. Mind boggling bureaucracy Bureaucracy will not be eased. It is set to get worse as eligibility for families to the $500 safety net is linked to the flawed Family Tax Benefit scheme. This year over 600,000 families have had to pay back overpaid benefits to Centrelink as they passed its various thresholds. To determine people's access to the Medicare system in future, their status will have to be determined by HIC Online — the same expensive broadband facility to be placed in doctors' surgeries that will enable the payment of those out-of-pocket expenses to the patient's bank account three days after they pay them up front. This means more hassles, more humiliation. This is exactly the pattern of treatment that followed the dismantling of the original bulk-billing system (Medibank) by the Fraser Government when Howard was Treasurer. No one expects the package to do much to attract nurses and doctors into the system and to stop the exodus from general practice. Much is made of items like the 234 places to be created each year in medical schools. Graduates from these courses would be bonded to practice in regional, rural and remote areas. However, by far the most costly of any of the recruitment items is the $432.5 million to be spent to recruit and support 725 overseas-trained doctors by 2007. The current crisis in GP numbers is due to the fact that most medical students in Australia no longer see general practice as viable. The Federal Government will be encouraging a brain drain from developing countries to help "fix" the problem their policies have created. They have consciously restricted Provider Numbers for new GPs for the last five years to reduce the bulk-billing outlays — a tactic that was recommended by "privatise everything" Productivity Commission. Labor health spokesperson Julia Gillard actually doubts the government will be spending $2.4 billion of "new money" over the next four years. She believes that it will be more like $800,000 and that many of the "Medicare Plus" items are accounted for in other outlays. In addition, the Government's figures are quite misleading, often giving total figures for the next four years — not how much next year. Quite often the money is not spent in later years, this has been particularly the case in the environmental area. However, the latest package is proposing to put a safety net under most out of hospital medical services. Dental services are not included. While there is a Medicare Benefits Schedule — which sets the rebate paid by the government for services like radiology and pathology — the existence of a "safety net" for patients would ensure that these costs would go through the roof. Corporate medicine will have no mercy when it can reassure patients that the Commonwealth will pick up 80 per cent of the tab. There is no "cap" or upper limit on what these providers can charge. In common with other measures taken in the health area by the Howard Government, "Medicare Plus" takes money out of the treasury vault and out of workers' pockets and gives it to corporate interests. Designed to fail The $2.4 billion estimate given for "Medicare Plus" could well blow out. This suits the Government's purposes. Speaking about his health portfolio last week, Tony Abbott concluded his listing of major budget items with the following observation: "One thing should be obvious from these astronomical figures: health care is not free." The careful choice of the term "astronomical" would not be made by someone committed to keep paying for expensive items like the Pharmaceutical Benefits Scheme. His longer-term objective is to have private hospitals and other corporate service providers dealing with patients with expensive private health insurance. The Commonwealth would be left to deliver a substandard service for those simply too poor to contribute to corporate profits. The immediate focus of the package is to get the Senate's approval for this latest attack on Medicare. While many of the measures contained in "Medicare Plus" can be implemented without the need for parliamentary approval, the adoption of its most important features does require some of the non-Labor forces in the Senate coming on board. "This package is the result of talks with the Democrats", Abbott points out and it appears that, with some reservations, the Democrats and key independents like Meg Lees have been "disarmed" by the sophistry used to sell it. The Health Minister expects "Medicare Plus" to pass largely untouched through the Senate before it rises for its break. The Greens today are calling for the $5 increase to be for everyone — not just pensioners and children — as a means of defending bulk-billing and its universality. This would be a step forward and would only cost $500 million. The provision of nurses to GPs who bulk-bill all of their patients would also be a strong incentive for doctors to bulk- bill. The coalition of forces that has come together over recent months to defend Medicare must alert the people to the dishonesty of the "safety net" propaganda being pedalled by the Howard Government. Those holding the balance of power in the Senate must be made to see that the people will not be "disarmed" by the package and will continue to defend all the vital elements of Medicare. Bulk- billing is affordable, it is the most cost — effective and socially desirable basis on which to build Australia's health system.