Recently I saw a patient who required admission to hospital because of sleep apnoea. She was a grossly obese woman in her forties who could often be heard snoring, head slumped on her bosom, in the waiting room.

She suffered pain in her knees, hypertension, diabetes and depression. Her weight was killing her. She had experienced verified episodes of apnoea lasting between thirty seconds and two minutes while she slept and these events had occurred 10 to 15 times per hour on several occasions.

A colleague and I had seen her several times. Weight reduction programmes, alcohol avoidance, improvement of nasal patency and intraoral devices had all failed. The nasal CPAP machine didn’t work.

The patient seemed to hover in limbo during the day and, after discussion, I decided to refer her to the sleep apnoea unit of a large public teaching hospital located 40 kilometres away for further assessment.

I rang the hospital, was transferred to the sleep apnoea unit and was told that if the patient had private health insurance she could be seen in two weeks otherwise she would have to wait nine months to be reviewed.

I asked to be transferred back to the switchboard and through to the Medical Superintendent of the hospital. An administrative medical registrar answered. I asked whether it had become public hospital policy to discriminate in favour of certain individuals on the basis of income. He apologised profusely and the patient was subsequently treated accordingly.

The "free market" intruded into this patient’s care to her detriment and had I not intervened, may have resulted in her dying prematurely before appropriate treatment would have been instigated.

Medicare is in decline. State governments have successively cut public hospital beds, staff and services in relentless "efficiency drives". The Coalition Government has health policy determined by the private health insurance industry and selected specialist medical practitioners.

The recent 30 per cent rebate for holders of private health insurance, subsidised by the general taxpayer to the tune of one thousand five hundred million dollars a year, should be ample evidence that the Coalition is locked into an archaic system of health financing. Tax rebates to assist meeting private health insurance payments, gap insurance and means tested public hospital care were features of the Coalition health policy in 1990. The then shadow Health Minister, Peter Shack, vehemently opposed Medicare and proposed policies to build up private health insurance.

Today however, the Government claims to be helping Medicare by implementing policies along the same lines as it did while being violently opposed to Medicare in 1990.

One can go back further. In 1953, the Liberal Government introduced the Voluntary Health Insurance Plan sponsored by Sir Earl Page. It provided for the subsidy of benefits to citizens who voluntarily joined private health insurance funds. The "Page" scheme persisted without substantial amendment until the late 1960s, when dissatisfaction with its operations led to the appointment of a Commonwealth Committee of Inquiry, under Mr Justice Nimmo, which published its report in 1969.

The major findings of the Nimmo Committee were as follows:

1. The operation of the health insurance scheme was unnecessarily complex and beyond the comprehension of many.
2. The benefit received by contributors was frequently much less than the cost of hospital and medical treatment.
3. The contributions had increased to such an extent that they were beyond the capacity of some members of the community and entailed considerable hardship for others.
4. The rules of many registered organisations limited claims for particular conditions, especially for chronic illness. The application of these rules was causing serious and widespread hardship.
5. An unduly high proportion of the contributions received by some organisations was absorbed in operating expenses.

Other recent mooted changes in health policy seem to show all the signs of restoring the cumbersome system of the past. Consider the notion of lifetime community rating. Now apparently, private health insurance premiums will be allowed to vary according to the patient’s age. The proposal is that a base premium would apply if the member joined at age 35 or below, the premium would increase by 2.5% for every of age over 35, and a maximum premium rate would apply after age 75 (at which the premium would be twice the base rate).

The rate applicable to the member’s age when joining would be maintained without change as long as membership continued (although all rates might increase over time). A break in membership of (say) one year or more would result in the loss of the lower rate (and the new premium rate on rejoining would be determined by age at that time).

There are more parentheses and caveats to this single proposal. Why go back to a complex and barely comprehensible system?

How easy would it be for my patient with sleep apnoea to get health insurance if the current irrational approach is allowed to continue? What premiums would she have to pay?

On the 6th June 1995, John Howard said, " They (Australians) want Medicare kept, and the coalition is fully committed to that. We shall also retain bulk-billing and community rating." (Headland speech).

Doctors should not be idle when patients insured through Medicare are denied treatment in public hospitals on the basis of ability to pay. Perhaps more doctors should insist on a fair go for all their patients. A sleeping giant might then wake and, through protest and the ballot box, make the Coalition stick to its commitment to retain Medicare in its entirety.

Dr Theo van Lieshout
Vice-President Doctors Reform Society of Australia

An edited version of this article was published as "Private health system may be terminal" in Australian Doctor April 1999.