Richard Trembath
When I suggested this article to the editors of Australian Policy and History (which is now some time ago) there was considerable discussion in the media about the strain on Australia’s health services, partly as the result of the pandemic, and partly as the result of long-term structural issues. For example, Chip Le Grand, an early, and trenchant, critic, of the Victorian government’s COVID policies, assessed the state of Medicare in December 2022:
Primary health care in Australia is funded by a broken model . . .[which] discourages general practices from providing the care people with chronic illness need to keep them out of hospital . . .There is broad consensus among healthcare experts that Medicare, a scheme designed at a time when people mostly went to doctors to treat injuries and infections, has not kept pace with changing demands in Australia, where two-thirds of the disease burden is now caused by chronic illness.
Le Grand’s proposed solution, drawn from the Grattan Institute, involves the creation of ‘multidisciplinary teams of clinicians’.[i] More of that later. Over the last four months discussion about Medicare ‘reform’ has strengthened: Mark Butler, the Federal Minister of Health and Aged Care, has recently announced a raft of changes, stating that there may be more, if necessary,[ii] state governments have offered various solutions, opinion pieces in the media have abounded, often reflecting wider political differences within Australian society. So, now, within a developing situation, I feel like someone trying to spray-paint the exterior of the car, while that vehicle is belting down the Western Highway.
In this article I shall place various views on the health of our health system within the appropriate historical context which goes back at least to the establishment of Medibank in 1975, and its resuscitation as Medicare in 1984 under the freshly elected Hawke government. Despite the frequent claim that our health system ‘is the envy of the world’ [iii] I contend that Medicare has not been universally accepted by Australian conservatives and is currently seen by many as ‘broken’, a term that is in danger of becoming a cliché in this context. The Albanese government has recently increased funding to Medicare, an initiative which I think is popular with the electorate. However, our national health arrangements are in a period where the threat of infectious disease has also focussed attention on how we deal with the medical and care problems associated with our extended life spans.
Medibank, Australia’s original national health scheme, was implemented in the last tortured year of the Whitlam government. Prior to that, the Federal presence in the nation’s health systems was limited. One of the more significant Commonwealth acts was the Chifley government’s establishment in 1948 of the Pharmaceutical Benefits Scheme. In a presage of what was to come, opposition to this measure from medical associations and conservative interests was venomous, prolonged and expensive, involving several High Court challenges and a referendum in 1946 which – amazingly – was successful and gave the Commonwealth power over some social services. Another early initiative was the implementation of free hospital care in Queensland in January 1946, created by a Labor administration, secure with a healthy gerrymander. It was preserved by its Country Party successors, who also enjoyed the benefits of a gerrymander, until it was subsumed into Medibank. Otherwise, as the ubiquitous Stephen Duckett states, ‘shambolic arrangements . . . characterised health insurance under the Liberals’ during the 1950s and 1960s with a reliance on ‘encouraging voluntary arrangements’, producing a system so Byzantine, experts struggled to explain it.[iv]
Despite being an ‘It’s Time’ campaign commitment in 1972, Medibank was one of those core proposals bitterly opposed by conservative parties, enraged at being ousted from power after holding it since 1949.[v] Their parliamentary obstruction of Labor legislation, including Medibank, led to a double dissolution in 1974 – which is not that unusual in Australia– but the subsequent joint sitting of Parliament is unique so far. Finally, Medibank got up, coming into effect on 1 October 1975. Six weeks later the Whitlam government was ousted. Malcolm Fraser reneged on this commitment to preserve a national health scheme and his government incontinently shed ministers in the Health portfolio, amending private insurance arrangements in an inept and ad hoc basis. As noted above, the Hawke government returned to a national health scheme in 1984, though ‘implementation of the policy was not easy’.[vi]
Let’s pause there in 1984, because that date is relevant, significantly so, to health politics in 2023. In the article by Stephen Duckett, which I have plundered for much of the previous two paragraphs, he notes that health ‘policy has totemic status in the Labor Party … unlike practically any other area of social policy . . . members have a strong commitment to universality as the basic organising principle for access to health care.’[vii] This is true to a large degree, though not totally, as out of pocket expenses rise for GP visits, dentistry, unlike in the United Kingdom, is not covered and rebated psychology sessions have been cut by the Albanese government. But public hospitals remain a bastion of the free and universal principle.
The Coalition is not always enamoured of Medicare. In 1993 John Hewson went to the polls in an election many commentators thought he could not lose. He promptly lost. His core proposal to introduce a Good and Services Tax was poorly argued and found little favour with the voters. But another factor in Hewson’s defeat was a proposal to remove bulk billing under Medicare except for those on concession cards, one of several health benefits to be removed. In 2016 Labor mounted a scare campaign, which may or may not have been justified, against the Turnbull government and its purported agenda of subverting Medicare. This was denied by the Coalition but the advertisements, which brought a very veteran Bob Hawke out of retirement, had their effect as Malcom Turnbull dropped fourteen seats.
And that surprise result was cited by Guardian economist Greg Jericho as support for Australians’ ‘love’ of our (partly) universal health scheme:
Australians overwhelmingly love Medicare. And they should. And they overwhelmingly hate private health insurance. Mostly private health care is now a thing taken out to avoid paying the Medicare levy surcharge. And more and more [of] what is being offered is insurance with a myriad of exclusions and excess co-payments.[viii]
As is clear from Jericho’s article, private health insurers in Australia don’t ‘overwhelmingly’ love Medicare; they probably don’t love it all. One significant legacy of the Howard years was his government forcing many younger Australians to take out private health insurance in order to avoid the punitive premiums they would encounter as they entered older age – private health insurance they might not use for three decades. Effectively, this is the government subsidising so called private enterprise. And that is still the case today though things could have been worse.[ix] Even before COVID stressed the health system further, private health executives, such as Mark Fitzgibbon of nib, sought to kink the system totally in their favour, calling for ‘compulsory private cover for all but the poorest Australians.’[x] In short, we would whizz back to the Sixties as bulk billing and free treatment in hospitals were, hey presto, extinguished. For right-wing journalists such as Adam Creighton, who look at Republican opposition in the United States to Obamacare and find it a savoury dish, a universal health scheme must be condemned in hysterical language, redolent of the Cold War. The following gem dates from 2011 although Creighton’s views remain the same:
But when it comes to health, Australians spurn pragmatism and tear up the laws of economics. We shackle ourselves with a government-funded and managed health system with all the hallmarks of the former Soviet Union – interminable queues, moribund buildings, hideous complexity, patchy service and a vast nomenklatura of bureaucrats and ‘health professionals’ who suckle on the public teat . . .
‘Universal’ healthcare burdens taxpayers while dulling incentives to be healthy. Someone else will ultimately pick up the tab. By contrast, private insurers would have a financial incentive to keep their customers healthy and adjust their premiums accordingly.
Routine gym attendance and a low cholesterol level or body mass index might, for example, elicit cheaper insurance. Financial incentives are more likely to mitigate the obesity epidemic than costly and demonstrably failed healthy eating campaigns.[xi]
Despite the over-the-top rhetoric, Creighton reminds us that the nature of illness and disability in Australia has changed since 1972. In that year, life expectancy in Australia was 71.46 – women, as always, doing better than men; in 2022 it was 84.32 for men and women combined. Even if we exclude the so-called lifestyle factors described by Creighton, we now live to an age where diseases such as cancer and degenerative syndromes are more common. These along with increased diabesity, for example, do not threaten immediate extinction. They do, however, promise sustained treatment from their first appearance until our deaths. In the developed world we are in the age of chronic affliction. Longer life is a great human achievement but ‘[s]ickness rates are much higher for the aged, and so are the amounts spent on health care.’[xii]
This was clear before COVID reminded us that infectious disease was not just something that happened somewhere else. How to adjust a health system which depends on two planks – the GP as conduit to further services, and a free hospital system – is another thing. In the year prior to COVID’s advent, Stephen Duckett wrote that Medicare funding ‘was slowly creeping into the 21st century’. The previous model ‘when medicine was essentially dealing with episodic conditions’ was ‘being supplemented with a new fee to better manage the care of people with diabetes’.[xiii] Again, we see an emphasis on new approaches to the treatment of a chronic disease.
COVID weighed heavily on a health system where staff shortages were already apparent, where demands for psychology appointments were rising, [xiv] where there were long waits for that complete misnomer, ‘elective surgery’[xv], where ambulances did not always turn up quickly, where out of pocket expenses for doctors’ appointments were rising and where waiting for specialist appointments in regional Australia was pure martyrdom. [xvi] By March 2022 the issue of ramping – ambulances queuing up outside hospitals waiting their turn to discharge patients – was prominent during the South Australian election campaign which concluded with the ousting of a single term government in a landslide. In fact, ramping might have been THE issue in that campaign.
This article started with Chip Le Grand informing us that our health system was a ’broken model’. Dramatic stuff, possibly exaggerated, yet I could pick a hundred media articles similar to Le Grand’s. Two quotes will do:
Hospitals miss emergency care targets as system cracks under pressure.[xvii]
Medicare is facing its biggest overhaul since its inception with Labor devising a ‘blended’ funding system that would up the delivery of primary care to a wider range of health professionals . . .in a bid to save universal health care. [xviii]
As Le Grand acknowledged, his suggested changes derive (without amendment) from the work of Stephen Duckett and the Grattan Institute. This schema builds upon the perceived change from acute illness being the cause of visits to your local doctor to chronic illness. In passing, I note that this might not be the case in newer suburbs such as those bursting up around Melton on the north-western fringes of Melbourne. There, I suspect, it is vaccinations, injuries, contraception, pregnancy and childhood illnesses which clog the waiting room, though in my local practice in Ballarat, with its extensive number of older patients, it is probably chronic illness.
The multi-disciplinary approach is advanced by those on the right like Creighton and those on the left like Ross Gittins. Unlike the former, Gittins does not assume that chronic disease is largely due to chip swallowing, beer drinking bludgers who need to be punished into taking care of themselves:
Over the almost 40 years of Medicare, there’s been a big change in the problems people bring to their GPs. Because we’re living longer, healthier lives, much more of our problems are chronic – someone with heart trouble or diabetes has to wrestle with it for the rest of their lives – rather than acute . . .
But the present (subsidised) fee-for-service way of remunerating doctors is designed to suit acute problems . . . it involves waiting for problems to arise, not early diagnosis or stopping chronic conditions getting worse . . .
Changing GPs’ surgeries into more wide-ranging ‘primary care clinics’ is also about making it easier for patients to move between different kinds of care, with GPs taking more responsibility for the total package.[xix]
Economists are irritating people. They can be so definite in their opinions, implying that if only numerical illiterates looked at the statistics, then all would be crystal clear. However, the dichotomy between acute and chronic disease, so useful for a media opinion piece, is not as clear cut as some would have it. Consider that piece of moonshine from Gittins that GPs sit back and wait for someone to come in with a full-blown illness. Now consider how many appointments with the GP are the prelude to checking that worrying mole, that persistent acidity, the breathiness and so on. The doctor might also decide that such testing is not necessary. We go to our local practice for those vaccinations we did not receive during infancy or at school – flu, shingles and so on. And where is the evidence that GPs are ‘allergic to change’?
There is also a virulence in the health policy debate, not as toxic or extreme as COVID critiques can be, but with ad hominem attacks to the fore. The Murdoch media are not the only culprits here. Try this gem from Chris Wallace in the Saturday Paper. The context is Health Minister, Mark Butler, being interviewed on ABC’s 7.30 program:
Butler’s banal, mealy-mouthed performance deepened concerns that there is a plodder at the helm of one of the portfolios of the moment. Collaborating with state governments on how to restore a close-to-broken primary healthcare system in Australia is a huge challenge and Butler does not look like that person. He can’t even manage straightforward public health challenges such as bringing down Covid deaths. [xx]
How can a relatively brief spot with Laura Tingle – or Neil Mitchell, Insiders, and whatever jocks are currently bloviating in Sydney – be taken as the basis for dismissing a minister from cabinet? Why should complicated policy decisions be treated in this facile manner? And what are Professor Wallace’s claims to give an expert opinion on the apparent ease with which COVID mortality can be reduced? There is a popular quote, often attributed to Mark Twain or H. L. Mencken, which has various versions, and the following is one of them: ‘Every complex problem has a solution which is simple, direct, plausible – and wrong.’
What Mark Butler did do on 3 February this year was announce measures for ‘strengthening’ Medicare. Broadly speaking, this entailed improving access to urgent care and general practitioners and digital health processes. Unsurprisingly, the Health and Aged Care Minister stated that Medicare ‘is one of this country’s shining stars, and it’s the backbone of our healthcare system.’ Despite the mixed metaphors there, we see that trope from Medicare’s supporters of how significant the publicly funded approach is to the Australian polity and our culture. The multi-disciplinary approach was also emphasised as there is a ‘critical need to use our health workforce more fully’ meaning such as ‘nurses and allied health professionals’. How this is to be done is not articulated fully.[xxi]
There is another, more wide-ranging approach to consider. As I have written before, COVID in Australia saw a plethora of books on life what might be after the illness left us, a happy state we have yet to reach, though you might be excused for thinking otherwise given its absence from the media. One of my favourite articles from this pop-up genre was written by prominent global health expert, Rob Moodie and two co-authors They advance the argument that if we reduce such causes of ill-health as smoking, alcohol abuse etc then a considerable proportion of common chronic illness would be prevented. Even Adam Creighton would agree with that argument. However, Moodie at al go much further:
Nearly 40 per cent of our disease burden and premature deaths could be prevented by reducing proximal risk factors such as tobacco use, overweight and obesity, and harmful use of alcohol . . . The second approach is to metaphorically ‘go upstream’ to prevent the causes of the causes (of poor physical and mental health). These include poor housing, poor urban design, poor education, unemployment and hazardous employment. Layering these is their intricate link with inequality, socioeconomic disadvantage and poverty, structural racism, intergenerational trauma, and decades of policies that have entrenched, rather than relieved, social exclusion.[xxii]
I would suggest that the two approaches need to be implemented simultaneously, and offer the omnipresent junk food industry, and its dismal consequences, as an example where real progress in improving public health could be made. But that task would be similar to taking on the tobacco giants and just as difficult, possibly more so. If I have not tried the editors’ patience, that could be the subject for another article.
So, where are we as summer gives way to autumn? Over the last fortnight the media’s attention has drifted away, it seems, from Medicare reform. If health is in the news it is focussed on staff shortages, service delays, aged care, Japanese encephalitis, the possible origins of COVID. Superannuation has some time to run as a hot issue surely. Yet, as well as Medicare funding arrangements, debate will continue on structural issues such as perceived shortages of GPs and nurses, the specific problems of the regions and the particular challenges faced by different groups in our society in terms of access and education. For some reason, it is so hard to avoid concepts such as class.
[i] Chip Le Grand, ‘Medicare overhaul needed to fix ‘broken’ health funding, report urges’, Sydney Morning Herald, 4 December 2022, https://www.smh.com.au/healthcare/medicare-overhaul-needed-to-fix-broken-health-funding-report-urges-20221204-p5c3gx.html
[ii] Australia, Department of Health and Aged Care, Minister for Health and Aged Care, Press Conference, 3 February 2023.
[iii] Nick Toovey, ‘Health care for all’, Age, 2 February 2022, https://www.theage.com.au/politics/victoria/health-system-for-all-20220101-p59l9c.html.
[iv] Stephen Duckett, ‘Making a difference in health care’ in Susan Ryan and Troy Bramston (eds), The Hawke Government: A Critical Retrospective, Pluto Press Australia, Melbourne, 2003, pp. 215-224.
[v] Paradoxically perhaps the Medibank proposal was not a particularly controversial issue during the campaign whereas abortion law reform and Labor’s union links were. See Laurie Oakes and David Solomon, The Making of an Australian Prime Minister, Cheshire, Melbourne, 1973.
[vi] Duckett, 2003.
[vii] Duckett, 2003.
[viii] Greg Jericho, ‘The proposal to privatise Medicare is bizarre. We should treasure our public health system’, Guardian, 28 July 2019, https://www.theguardian.com/business/grogonomics/2019/jul/27/the-proposal-to-privatise-medicare-is-bizarre-we-should-treasure-our-public-health-system
[ix] For the Howard initiatives see Greg Jericho, ‘Is private health insurance a con? The answer is in the graphs’, Guardian, 6 February 2018, https://www.theguardian.com/business/grogonomics/2018/feb/06/is-private-health-insurance-a-con-the-answer-is-in-the-graphs
[x] Lucas Baird and Tom McIlroy, ‘Health insurers to face revenue headache: Goldman Sachs’, Australian Financial Review, 16 July 2019, https://www.afr.com/policy/health-and-education/health-insurers-to-face-revenue-headache-goldman-sachs-20190716-p527kl; Mark Fitzgibbon, ‘Universal healthcare need [sic] private insurance for survival’, Australian Financial Review, 23 July 2019, https://www.afr.com/politics/universal-healthcare-need-private-insurnce-for-survival-20190722-P529i9; James Fernyhough, ‘Scrap Medicare, mandate private health cover: NIB boss’, Australian Financial Review, 23 July 2019, https://www.afr.com/companies/healthcare-and-fitness/scrap-medicare-mandate-private-health-cover-nib-boss-20190722-p529iw,
[xi] Adam Creighton, ‘There’s no such thing as a free healthcare system’, Sydney Morning Herald, 27 August 2011. See also, Adam Creighton, ‘The sickening cost of healthcare’, Australian, 11 October 2013. For a more recent statement of such views from another Murdoch stalwart see Ticky Fullerton, ‘NHS Creaks Under Strain’, Australian, 17 January 2023.
[xii] James C. Riley, Rising Life Expectancy: A Global History, Cambridge University Press, New York, 2001, p.232.
[xiii] Stephen Duckett, ‘Budget 2019: A hesitant step for Medicare, The Conversation, 2 April 2019, https://grattan.edu.au/news/budget-2019-a-hesitant-step-forward-for-medicare, accessed 23 January 2023.
[xiv] Nicholas Jensen, ‘Fear of psychologists’ exodus after cut back’, Australian, 17 January 2023.
[xv] Melissa Cunningham, ‘ “You just break down”: The long, agonising wait for surgery in Victoria’, Sunday Age, 19 February 2023.
[xvi] Even as late as March 2022 it could plausibly be claimed that that ‘the vast majority outside of hospital are bulk-billed – meaning the patient pays nothing out-of-pocket’. That statement would have to be qualified now. Stephen Duckett, Anika Stobart and Linda Lin, ‘Not so universal: How to reduce out-of-pocket healthcare payments’, Grattan Institute, March 2022, https://grattan.edu.au/wp-content/uploads/2022/03/Not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments-Grattan-Report.pdf.
[xvii] Sumeyya Ilanbey, ‘Hospitals miss emergency care targets as system cracks under pressure, Age, 29 December 2022, https://www.theage.com.au/politics/victoria/hosipitals-miss-key-emergency-care-targets-as-system-cracks-under-pressure-reports-show-20221229-p5c980.html
[xviii] Natasha Robinson, ‘Shake-up for ‘unfit’ Medicare, Australian, 23 January 2023.
[xix] Ross Gittins, ‘If GPs want more money, they’ll have to be less allergic to change’, Age, 8 February 2023.
[xx] Chris Wallace, ‘Summertime and the leading is easy’, Saturday Paper, 21-27 January 2023.
[xxi] Australia, Department of Health and Aged Care, 2023.
[xxii] Rob Moodie, Tasmyn Soller and Mike Daube, ‘Reimagining public health in Australia’, in Emma Dawson and Janet McCalman (eds), What Happens Next? Reconstructing Australia After Covid-19, Melbourne University Press, Melbourne, 2020, pp. 197-206.
