“Time to think of patients”

Dr Andrew Gunn

Australian Doctor

17 Oct 2003

Prime Minister John Howard has a vision of Australia with less community and more individual responsibility. Universal health cover via Medicare and public hospitals irritates Mr Howard because this makes health care a community responsibility.

His personal philosophy entails that people who do not plan for their own health care should not receive it. Regrettably, even health care providers may not recognise how this creates poor health outcomes. Doctors often seem unable or unwilling to comprehend their patient’s lives.

Many years ago, I listened to a psychiatrist rail about a patient. The man had been regulated and sedated in Accident and Emergency against his will and, due to a lack of inpatient beds, moved by ambulance to another hospital. The patient then had the temerity to complain that the ambulance service had sent him a bill for several hundred dollars. The psychiatrist believed that this man should pay his bill. After all, the patient knew that he had a chronic illness and could have chosen to subscribe to the ambulance, thereby receiving free transport (as was the case at the time).

I have always regretted not saying to the psychiatrist that this man must have been a lunatic not to be an ambulance subscriber.

Lots of doctors don’t approve of Medicare. This goes back a long way. Mr Howard has been able to claim that he is not eliminating our universal health system because Medicare, and specifically bulk billing, was never universal.

Although bulk-billing was never universal, this was arguably due the actions of conservatives and doctors in the 1940’s when a Labor Federal Government passed legislation to provide various pharmaceuticals without charge. The Australian branch of the British Medical Association, alarmed that any health care might be “free”, challenged its legality in the High Court and won.

The government’s response was a referendum to alter the constitution so that legislation of this type would be permitted. The referendum passed but not before, at the behest of the medical association, Robert Menzies succeeded in inserting a short bracketed clause that outlawed the “civil conscription” of medical and dental services. It has largely been this clause, as yet unchallenged in court, that ensured Australia’s future included uncapped fee-for-service medicine and inadequate rural medical services.

Mr Howard claims his proposed Medicare changes will support bulk billing when, in reality, they make it both easier and more attractive to reduce bulk-billing. He also says his package will improve access to health services. Yet the international evidence is that co-payments do not improve access for the sick by deterring the less unwell from seeing doctors. They do, however, improve access for the wealthy by deterring the less well-off, and do create poor health outcomes. Co-payments restrict services according to wealth, not health.

We have two current alternatives to find extra money for GPs: public funding or private co-payments. Public funding means high-income earners contribute the most. Co-payments mean the sick - and disease burden is also associated with low socio-economic status - contribute most.

Mr Howard’s package will create a multi-tiered system. The wealthy may find it cheaper because, for them, private provision for health care is cheaper than supporting the less well off via tax. The low-middle income group lose whether or not they choose to spend up on private insurance.

Those eligible for a safety-net may or may not be able to access care and that care will become second-rate.

Medical associations have an appalling record of supporting measures that enrich themselves but harm community health. Policy decisions, like clinical decisions, are best made after a dispassionate assessment of their health effects. Let’s hope, as doctors, we can do this.