BY SARAH STEPHEN
In the past six years, there has been a rapid decline — from 80% to 70% — in the proportion of doctors who bulk-bill their patients, charging the government direct, rather than charging the patient a fee. If this rate of decline were to continue, no doctors will be bulk-billing by September 2016.
While this is a alarming trend, a symptom of a health system that is suffering massive strains, it is not a crisis that is impossible to turn around.
Yet Prime Minister John Howard would have us believe otherwise: Australia's health system is becoming impossibly expensive, costs are soaring due to an ageing population, and Medicare is becoming too costly for the government to sustain. Howard recently told parliament "it is simply not possible for the government ... to guarantee bulk-billing for every Australian citizen".
Howard argues that it is everything but his government's policy which is causing the health crisis. Yet that is precisely what's responsible.
The federal Coalition government is committed to the privatisation of Australia's health system, with a greater emphasis on fee-for-service health care at the expense of public funding.
The corporate elite is increasing pressure on the government to reign in health spending, which currently stands at around 8% of GDP. Expressing the views of big business, a February 25 editorial in the Australian Financial Review argued: "It is obvious that taxpayers cannot continue throwing more money at health care without imposing some disciplines on spending... most patients can and should make a co-payment when they see a GP, which would impose some discipline on GP visits."
It was the previous Labor government, under Bob Hawke's leadership, that first floated the idea of a $3.50 "co-payment", a fee paid by a patient to "top up" the amount paid to a GP by Medicare. Then deputy prime minister Brian Howe argued that the scheme was aimed at curtailing "over-servicing" by some GPs. The proposal was reduced to $2.50 before being scrapped due to strong public opposition.
Both Labor and Coalition governments have starved Medicare of funds. In 1991, the Medicare rebate for a standard consultation was around $20. Now, 12 years later, it is only $25. The rebate hasn't kept up with inflation, let alone the rising costs of practising medicine, such as medical indemnity insurance.
The doctors' peak body, the Australian Medical Association, agrees with the government that people who need health care will not find a co-payment any disincentive. AMA president Kerryn Phelps argues that there will not be a strain on public hospitals as the poor turn to them for free treatment.
But the real world already tells a different story. In Brisbane, there has been a 17.7% fall in bulk-billing in the past two years. There are fewer practices open after hours and GP numbers are declining. In the last 12 months, the number of people who can't get an after-hours doctor, or who can't afford the up-front payments; and who are instead coming into the emergency department of Logan Hospital in South Brisbane has trebled.
The February 25 Sydney Morning Herald revealed health department figures which show a decline in the number of visits people make to a doctor in areas where bulk-billing has declined the most. In Queensland, where the number of GPs who bulk bill has dropped by 5.4% in the past year, doctor visits have fallen by 1.5%; in South Australia, with a bulk-billing drop of 4.9%, doctor visits are down 2%.
At present, Medicare rebates cost around $6.3 billion a year, one-eighth of the $50 billion federal health budget. In a plan to end the bulk-billing crisis released on March 10, the National Medicare Alliance (NMA) called for an increase in the Medicare rebate by scrapping the private health insurance 30% rebate, which currently costs the government $2.5 billion — money that has been diverted from the public health system to be handed as a tax rebate to those who take out private health insurance.
The NMA plan also calls for incentives to increase the number of doctors who bulk bill, including a higher rebate for bulk-billed consultations than for those where the doctor charges an up-front fee and the patient later claims the Medicare rebate. The plan also calls on the government to reassess the cap on GP numbers and investigate the viability of establishing government-run medical centres.
Contrary to the AMA's view that Medicare need only be a safety net for the poor, the NMA argues that Medicare must remain the core of a universal health care system which ensures the same standard of care is provided to people regardless of their capacity to pay.
One of those involved in designing Medicare in the early 1980s, Dr John Deeble, wrote in the March 8 Sydney Morning Herald: "Medicare is not a discretionary government handout. Nor is it a welfare scheme. It is an insurance system to which everyone contributes according to their income."
In an opinion piece in the March 8 Sydney Morning Herald, columnist Adele Horin wrote: "Before there was Medicare (known as Medibank in the 1970s) there was private insurance to cover doctor's bills for those who could afford it. Large families, the chronically ill, the poor, were reluctant to go to the doctor; or they did not pay their bills. In the early '70s unpaid medical bills were the biggest single category in the small claims court."
Horin observed that the Fraser Coalition government, in which Howard was treasurer, "dismantled Medibank, allowing only health card holders — the deserving poor — to get bulk-billed".
Introduced by Labor in 1984, Medicare was based on the principle that everyone has the same entitlement to good quality health care, and that access to health care should be based on health needs rather than an individual's ability to pay. The vast bulk of funding coming from taxation and the Medicare levy means that those who earn the most also contribute the most.
A Friends of Medicare fact sheet tackles the myth that the well-off are freeloading on the public system, and that Medicare should be a safety net for the poor. It argues: "The strength of Medicare is that it is for all of us. Everybody pays a fair proportion dictated by their income. The 'well-off' pay more because they can afford to do so. If Medicare became only a safety net for the 'poor' and the more 'well-off' were 'encouraged' to use the private health system and contribute less to Medicare, Australia would see the destruction of our equitable health system.
"If Medicare was no longer universal, well-off people would no longer have a stake in its quality. The poor and sick would then be worse off, not better, as the level and quality of care declined."
Presently, Medicare is largely funded through the Medicare levy, which is a 1.5.% levy paid by everyone with a taxable income above $14,500. Individuals with taxable incomes of more than $50,000, and families with taxable incomes of more than $100,000, must pay an additional surcharge of 1% if they don't have private health insurance.
The Howard government cares very little that the cost of health care for individual Australians may increase dramatically as it takes us down the road of privatisation, because its goal is only to decrease the amount of public funds that go into the health system.
"An equally important reason to retain Medicare as we know it is to restrain doctors' fees", Horin argues. "Once doctors are free to charge patient top-ups, health costs will start to spiral, the government will be under no pressure to keep up its contributions, and patients will need to insure for the gaps. We'd be back to the pre-Medibank era. It happened in New Zealand. Doctors' fees crept up and the real value of the government's payment was allowed to wither to the point where people forgot it even existed."
From Green Left Weekly, March 19, 2003.
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