Medicare is based on the belief that health care is a shared civic good with community responsibility. We are all affected by our own health and the health of others. There are benefits from universal health care for everyone no matter how often we may require it. We do not know when or where illness may occur so we all chip in together to provide for health care. This is the ‘communitarian’ universal approach.

This approach can clash with the view that health care should be driven by market forces and individual responsibility with limited ‘government interference’. This is the free market, United States two- (or more) tiered system which relies on private insurance, user fees and safety nets for the ‘poor’. Prime Minister John Howard is a long term supporter of this view and his government’s disingenuous ‘A Fairer Medicare – Better Access, More Affordable’ package moves us in this direction.

Health care can be funded publicly or privately - publicly through taxation and privately through private insurance and user fees such as co-payments. The principle of receiving care according to need and paying according to means is essential to the original intent of Medicare. Payment according to means involves collectivised financing through taxation rather than paying at the point of service. Access, equity and universality are promoted by not having to pay up-front to obtain health care. Bulk-billing has provided this within a fee for service system. Bulk-billing is a foundational element of Medicare. User charges such as co-payments ignore the unequal ability to pay and the unequal need for health care. As will be discussed in Part 2 of this article (New Doctor #79), co-payments reduce access for the less well-off, improve access for the wealthy and place a higher financial burden on the sick and less well-off.

Howard’s ‘A Fairer Medicare’ package encourages co-payments and a further shift to private health insurance (PHI). This repeats past debates and battles. Co-payments in the healthcare sector have been touted at various times by both the Australian Labor Party (ALP) and Liberal-National Coalition Governments as a means of controlling growth and providing finance.1 Both the current federal government and the ALP have supported the 30% PHI rebate although the ALP finally appears to be seriously reassessing this position. The Australian Medical Association (AMA) has consistently supported co-payments, the PHI rebate, tax cuts for the wealthy with PHI, safety nets for the poor and opt-out schemes.

Proposed ‘solutions’ to financing Medicare that involve co-payments, ‘targeting’ particular groups such as concession card holders and a push to the private sector would result in a more expensive, inequitable system. Limiting bulk-billing to a select group deemed ‘disadvantaged’ would reduce Medicare to a welfare system for the poor, with many Australians unable to afford access to the care they need. This would be the death of Medicare and has consistently been Howard’s and the Australian Medical Association’s (AMA) agenda.

The Liberal Party and AMA have a strong history of opposition to Medicare’s principles. The Coalition opposed the introduction of Medibank in 1975, Medicare in 1984 and despite prior promises to the contrary began dismantling Medibank soon after their election in 1975.2 Howard was Treasurer in the Fraser government during this time. They again planned to get rid of Medicare in their Fightback! Policy (which many believe lost them the "unlosable election"in 19933).

During his long political career, Howard has described bulk-billing as "scandalous" and an "absolute rort". He has described Medicare as a "miserable cruel fraud", a "scandal", a "total and complete failure", a "quagmire", a "total disaster", a "financial monster" and a "human nightmare". He has said he would "pull Medicare right apart" and "get rid of the bulk-billing system", confine bulk-billing to pensioners and the disadvantaged, allowing doctors to charge whatever fees they chose. He has also said that only pensioners and the disadvantaged should be entitled to free hospital care.4 Means testing and ‘affordable’ co-payments for public hospitals may well be next on Howard’s agenda.

Medicare has consistently been popular with the Australian people. Since the 1993 election loss, Howard has bided his time, muting his convictions due to the realisation that harming Medicare loses votes. As AMA federal president Dr Kerryn Phelps let slip: "the problem for governments is that Australians love Medicare".5 Howard’s public position consequently changed to "we are going to keep Medicare lock, stock and barrel", "unequivocally retain bulk-billing" and "maintain Medicare in its entirety". Howard has, however, completely redefined Medicare and universality.

The government has allowed things to deteriorate so as to make ‘needed changes’ that may seem like a good idea in the circumstances but would lead to the eventual downfall of Medicare. John Howard and the momentarily materialised Invisible Woman, Health Minister Senator Kay Patterson, are sanitising their current package for public consumption with deceptive notions of "universality", "affordability", "fairness", "improved access", "reviving bulk-billing" and "maintaining Medicare". All examples of doublespeak.

The medical profession, the private health insurance industry and private hospitals form powerful lobby groups who benefit financially from expansion of the private sector and the devolvement of Medicare. The AMA has consistently opposed bulk-billing and the principles behind Medicare. This goes back to blocking a national health program in the 1940s as the Australian branch of the British Medical Association and successfully lobbying Menzies to support the insertion of a bracketed eleven word clause in the constitution disallowing ‘conscription’ of doctors in 1946 (emboldened below).

This clause is why 100% bulk-billing was not originally enforced with Medibank.7 Although never tested in court, these few words have meant federal governments have not pursued authority over medical incomes or workforce distribution.

Since the successful lobbying in the 1940’s, the AMA has opposed the introduction of Medibank in 1975 and Medicare in 1984, proposed the user-pays Medicover scheme in 1989, supported the diversion of money away from the public health system through tax concessions for high income earners8 and are again attempting to reduce Medicare and bulk-billing to a safety net for the ‘genuinely disadvantaged’. The AMA has solidly supported and called for co-payments. Recent comments from AMA national president Dr Kerryn Phelps include:

The stage has been set by both the government and AMA to undermine Medicare and decrease public confidence in public health care. The idea that there is no alternative is being pushed onto the public. It is said to be inevitable that we cannot fully fund Medicare publicly and that bulk-billing cannot be sustained. This rhetoric is designed to enable the government to introduce policies that destroy Medicare and replace it with their ideologically preferred market-based, user-pays approach. The AMA has recently been bemoaning the demise of Medicare and bulk-billing while at the same time trying to convince the public that this is inevitable.

Other recent comments from Dr Phelps include:

Medicare, however, is as relevant as ever. Medicare is currently our only chance of a universal health care system that is based on care according to need and payment according to means and not one dictated by market forces like in the USA.

The Royal Australian College of General Practitioners (RACGP) has not been strong in defending the principle of universal health care and bulk-billing. They have referred to "appropriately targeted private billing" and produced a Private Billing Education Kit to "help GPs around the country determine when, how and if to commence private billing" and "consider whether they might move away from bulk billing".13 Speaking at the launch of the kit Dr Claire Jackson summed up:

The RACGP has described the Federal Government "as being committed to ensuring that Australians with health concession cards will have access to affordable general practice services" whilst expressing concern that within the package there was "no safeguard for working families and individuals on low incomes who do not have a health concession card. This creates a two-tier system." 14

The AMA has likewise claimed they do not want a two-tiered system – "one for the haves and one for the have-nots".4 The philosophy and policies they promote, however, would do just that. It has also been said that we already have a two-tiered system and there has been a lot of talk about making the system more ‘affordable’. By affordable what the AMA is implying is direct billing to the HIC with patients paying a co-payment (except for the ‘genuinely disadvantaged’). What is affordable to the AMA is open to question. Dr Phelps believes a $20 co-payment is affordable and has likened paying doctors to paying hairdressers, accountants and lawyers.15 Dr David Rivett chairman of the AMA council of general practice has stated that "Too much concern is being expressed about the social consequences of an end to bulk-billing. As I have said before, this is Australia, not Biafra. Most patients can afford a moderate co-payment." 16

The DRS was formed to support the introduction of universal health coverage and ever since has strongly supported the principles of Medicare. Although the DRS often seems a lone voice among the medical profession, the Royal College of Physicians (RACP) recently provided strong support.

This is in stark contrast to the RACGP. The recent 2003-04 RACGP membership renewal letter proudly boasts advocacy on "issues which affect the ability of GPs to deliver high quality care" including "strong and practical support for GPs who wish to move away from bulk-billing".

How health care is funded affects both cost and fairness. Publicly funded universal health insurance schemes, such as Medicare, provide the most equitable and cost effective health systems.18-23 The World Health Organization’s "European Health Care Reform Analysis on Current Strategies" concluded that a comparatively high level of government involvement is required to ensure that health services are accessible, efficient and adequately funded.21 The competitive market does not deal adequately with issues of public interest and equity. Public systems are better able to serve individual and population needs.18 Major health accomplishments are not the result of unregulated market forces. Rather, they are products of government action, legislation and regulation. The situation seen in the USA indicates the failure of market provision of health services backed with limited government subsidies and involvement. It is more expensive, less efficient, less equitable and creates worse health outcomes.20,24-31

The spread of PHI leads to greater healthcare expenditure. The larger the private sector the higher the total cost of a health system.32,33 Increases in the public share of finance and control of healthcare have been linked to decreases in healthcare expenditure to GDP ratios.34-36 This has been attributed to higher administrative costs and fewer cost controls in the private sector.20,24,29,37-39 In Australia, administrative costs of private health funds are around four times those of Medicare administered through the Health Insurance Commission (HIC).40,41 Governments and single national insurers such as Medicare are in a better position to exercise greater market power (through regulation and monopsonistic control) and to contain expenditures through global budgets and price and volume controls.38,42 Studies consistently show that for-profit hospitals are more expensive than not-for-profit hospitals.43-45 For-profit hospitals have also been documented to have poorer outcomes.46

Increases in private spending on health are associated with declines in public spending. Increasing the relative size of private finance substitutes for, rather than supplements, public funding. There is no evidence that waiting lists in the public sector are reduced by allowing privately insured options. Long public waiting lists appear to fuel demand for private insurance but private options do not reduce the length of public waiting lists. There is evidence that parallel private systems "cream-skim" the relatively healthier patients and leave the sicker patients to the public sector.36

Of OECD countries, Australia is second only to the United States in the size of the private health sector. The privatisation policies pursued by the Howard Government have increased private insurance coverage from approximately 30 to 45 per cent of the population. It is no coincidence that Australia’s health care costs have risen by 18 per cent in the last two years.47 The greatest rises in expenditure in the healthcare sector have been in the private sector.34,48-50 For example, an Auditor General’s review of the experience with privatisation at Port Macquarie Hospital in NSW found it cost almost three times what it would have cost if the government had built the hospital. Over 20 years the government would have paid for the hospital more than twice yet would not own it.51

The PHI rebate has been shown to be an inefficient use of resources. It has not taken ‘pressure off public hospitals’ and has mainly benefited the better off. On both economic and health service criteria, the rebate has failed to produce the results claimed for it. The expenditure on the rebate could have been spent more efficiently and equitably through supporting public hospitals directly.52-54 The current direct cost to the tax payer of the PHI rebate is $2.3 billion and rising. The PHI industry now receives more budgetary assistance than that provided to the mining, manufacturing and primary agricultural production industries combined.55 Experience indicates that PHI industry cannot survive without taxpayer subsidy unless the public system is so poor that people feel forced to insure privately.47

The Medicare levy surcharge exemption provides further assistance for the PHI industry and tax subsidies for the wealthy. This has been under-estimated and hidden from public scrutiny and regular review due to the government classifying the exemption as a tax ‘penalty’ on those choosing not to purchase PHI rather than as industry assistance. Other industries receiving high rates of assistance have been subject to regular, public scrutiny and restructuring.55 Smith has questioned the precedent set by the imposition of a discriminatory tax on individuals choosing not to purchase a commercial product.54 The cost of revenue forgone by the Medicare levy surcharge exemption has been estimated to be between $750 and $1,100 million annually.56,57

To make a saving from their tax exemption, high income earners (>$50,000 for individuals, >$100,000 for families) only need to buy a PHI package costing less than 1% of their taxable income. For individuals on $50,000 this would be less than $500. It has been documented that high-income tax payers who have no desire to take out health insurance are purchasing low price packages specifically for the purpose of avoiding the Medicare Levy Surcharge. The amount of tax avoided by the use of such PHI policies has been estimated to be between $99 and $180 million per annum.58

Private health insurance, unlike co-payments, redistributes health care expenses especially with community rating. PHI premiums, however, are flat fees and not progressive like general taxation. Everyone pays the same for the same product regardless of income. This becomes very regressive with the 30% PHI rebate and tax exemptions from the Medicare levy for high income earners with PHI. The PHI rebate mainly benefits the wealthy and abounds with inequities. These tax subsidies are highly regressive in themselves59 but have other incongruous equity consequences. Approximately half of the present open-ended PHI subsidy goes to the top 20 per cent of taxpayers and nearly three quarters goes to the top 40 per cent. This contrasts to progressive distribution of direct public spending on health.60 Around a quarter of the tax subsidy may be spent on ancillary rather than hospital insurance.55

A resulting blatant disparity is that via the PHI rebate, the federal government subsidises private dental services, received principally by high income earners, over $103 million annually while a successful federal public dental health scheme directed at low-income earners at a cost of $54 million annually was axed as a cost cutting measure in 1996.53 A huge sum of public money must also be spent subsidising gym and golf club membership, gym shoes, golf clubs, tennis racquets and so on to improve the ‘health’ of the wealthy.

The current government proposal to allow gap PHI for out-of-pocket costs over certain thresholds is another foot in the door for the PHI industry. If introduced this will extend over time and result in further erosion of Medicare and an increasing reliance on PHI coverage. Of the package’s $917 million over four years, $89.6 million is the estimate required to fund the 30% rebate of new PHI gap coverage.61 Going by past experience with the PHI rebate this estimated cost to the tax payer is likely to blow out.

Diversion of tax dollars from the public system to the private system threatens political sustainability as it creates a constituency not committed to Medicare.47 Loyalty to the universal system and preparedness to contribute may be eroded. Traditional solidarity and loyalties to a shared system may be broken once people start to see themselves as consumers rather than as citizens. As Morone states in Citizens or Shoppers? Solidarity under Siege "(c)itizen solidarity fades into consumer shopping".62 The next step is opt out schemes. Death of Medicare under Howard ã la death of Medibank under Fraser.

Powerful sections of the medical profession, including the AMA, strongly oppose government regulation or ‘interference’ in the delivery of health care. They appear to believe that the doctor-patient relationship is an exclusive domain where financial transactions between doctor and patient are some sort of inviolable exchange that ensures quality, satisfaction and appreciation. This sometimes seems to take on the zealot tone of the radical right where the government is seen as the enemy and minimalist government is the goal.

The AMA pushes a similar line:

This sentiment against government intereference does not, however, prevent voracious calls for government action when it suits the profession. One need look no further than the current medical indemnity crisis for a good example.

Part 2 of this article will be published in New Doctor #79. It continues the discussion of problems with the Government’s Medicare package, in particular, co-payments.

1. Co-payments on GP visits were proposed in the 1991 Labor federal budget and by Liberal Government backbencher Dr Brendan Nelson in 1996.

2. See Dr Alf Liebholt "Reflections on Bulk-billing" p9 on DRS lobbying in 1978 against the AMA for the retention of bulk-billing during the Fraser government and the Flashback Article p29 from 1983 of Professor George Palmer for a history of Medibank to Medicare.

3. Gray G. Reform and Reaction in Australian Health Policy. Journal of Health Politics, Policy and Law 1996;21:596-597.

4. Costello M. PM’s sincerely busy faking it, The Australian, 2 May 2003

5. Phelps K. Government fiddles while Medicare burns: The Public Record 26/11/02, ABC Online http://www.abc.net.au/public/s735087.htm

6. Commonwealth Of Australia Constitution Act, 1946 Chapter I The Parliament, Part V - Powers of the Parliament http://www.aph.gov.au/senate/general/constitution/par5cha1.htm

7. Blewett N. Bulk-billing for all isn’t passé, The Australian, 3 March 2003, 2003.

8. Phelps K. Transcript of Media Conference - Dr Kerryn Phelps, AMA President, Parliament House, Canberra - AMA Federal Budget Submission 2003-2004, 13 February 2003, http://www.ama.com.au/web.nsf/doc/WEEN-5JQ8MN

9. Phelps K. Speech by AMA President, Dr Kerryn Phelps to the Sydney Institute - The Future of Medicine in Australia, 24 Februrary 2003, http://www.ama.com.au/web.nsf/doc/WEEN-5K39W2

10. AMA Media Release. Prime Minister confirms need for Medicare ‘safety net’, 3 March 2003, http://www.ama.com.au/web.nsf/doc/WEEN-5KABRR

11. Interview - Dr Kerryn Phelps, AMA President, with Nicole Haack, Radio 5AA - The declining number of doctors offering bulk billing, 11 February 2003, http://www.ama.com.au/web.nsf/doc/WEEN-5JN9U8

12. Now the brakes are off the slide is speeding up, Australian Doctor, 21 February 2003

13. RACGP Media Release. General Practice - Endangered Species? 1 March 2003: Royal Australian College of General Practitioners, http://www.racgp.org.au/document.asp?id=8803, 2003.

14. RACGP Media Release. Commonwealth Medicare Changes Fail To Address General Practice Crisis, 28 April 2003: Royal Australian College of General Practitioners, http://www.racgp.org.au/document.asp?id=9505

15. Medicare overhaul should be put to voters, says consumer watchdog, The Australian, 22 April 2003, 2003.

16. Rivett D. Medicare myths help no one Gut Feelings: Australian Doctor, 6 March 2003, 2003.

17. RACP, ACA. Media Release, 11 March 2003 Physicians and consumers demand support for Medicare: Royal Australian College of Physicians and the Australian Consumers’ Association

18. Blendon RJ, Schoen C, DesRoches CM, Osborn R, Scoles KL, Zapert K. Inequities In Health Care: A Five-Country Survey. Health Affairs 2002;21:182-191.

19. Chernichovsky D. Health system reforms in industrialised democracies: An emerging paradigm. The Milbank Quarterly 1995;73:339-372.

20. Goldberg MA, White J. The Relation between Universal Health Insurance and Cost Control. N Engl J Med 1995;332:742-744.

21. Saltman R, Figueras J. Analyzing the evidence on European health care reforms. Health Affairs 1998;17:85-108.

22. Schoen C, Davis K, DesRoches CM, Donelan K, Blendon RJ, Strumpf E. The Commonwealth Fund 1998 International Health Policy Survey: Health Insurance Markets and Income Inequality: Findings from an International Health Policy Survey. Health Policy 1998;April.

23. Deeble JS. Medicare: Where have we been? Where are we going? Aust N Z J Public Health 1999;23:563-570.

24. Anderson G, Poullier J. Health spending, access, and outcomes: Trends in industrialized countries. Health Affairs 1999;18:34-41.

25. Anderson J, Hussey P. Comparing Health System Performance in OECD Countries. Health Affairs 2001;20:219-232.

26. Iglehart JK. The American Health Care System- Expenditures. New England Journal of Medicine 1999;340:70-76.

27. Pollock A, Rice DP. Monitoring health care in the United States - a challenging task. Public Health Reports 1997;112:108-114.

28. Wagstaff A, van Doorslaer E, van der Burg H, Calonge S, Christiansen T, Citoni G, Gerdtham U-G, Gerfin M, Gross L, Hakinnen U. Equity in the finance of health care: some further international comparisons. J of Health Economics 1999;18:263-290.

29. Woolhandler S, Woodlander D. Cost of care and administration at for profit and other hospitals in the United States. N Engl J Med

1997;336.

30. Anderson GF, Petrosyan V, Hussey PS. Multinational Comparisons of Health Systems Data, 2002. New York: The Commonwealth Fund, 2002.

31. Budetti J, Duchon L, Schoen C, Shikles J. Can’t Afford to Get Sick: A reality for millions of working Americans. New York: The Commonwealth Fund, 1999.

32. Newhouse J, al e. Free For All? Lessons from the Rand Health Insurance Experiment. Cambridge: Harvard University Press, 1993.

33. Peden EA, Freeland MS. A Historical Analysis of Medical Spending Growth, 1960-1993. Health Affairs 1995;Summer:235-247.

34. Carter M. Is Medicare Sustainable Sustaining a health future: a consumer consultation on the future of health financing in Australia. Brisbane, 1999.

35. Butler JRG. Health Expenditure. In: G Mooney, Scotton R, eds. Economics and Australian Health Policy. St Leonards: Allen and Unwin, 1998:41-49, 66-68.

36. Hughes Tuohy C, Flood CM, Stabile M. How Does Private Finance Affect Public Health Care Systems? Marshalling the Evidence from OECD Nations. Journal of Health Politics, Policy and Law 2001.

37. Reinhardt UE, Hussey PS, Anderson GF. Cross-National Comparisons Of Health Systems Using OECD Data, 1999. Health Affairs 2002;21:169-181.

38. Maynard A, Dixon A. Chapter Five - Private health insurance and medical savings accounts: theory and experience. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002:109-127.

39. McAuley I. Death is Inevitable, Why Aren’t Taxes? - The Commonwealth’s Intergenerational Report: The Drawing Board: An Australian Review of Public Affairs, University of Sydney http://www.econ.usyd.edu.au/drawingboard/digest/0206/mcauley.html

40. Livingstone C. Private Health Insurance: a triumph for market ideology. Health Issues 1997;51:27-29.

41. Friends of Medicare Alliance. Friends of Medicare Information Kit Fact Sheet 4. New Doctor 2001;75, Winter 2001.

42. Donato R, Scotton R. The Australian health care system. In: G Mooney, Scotton R, eds. Economics and Australian Health Policy. St Leonards: Allen and Unwin, 1999:22-27.

43. Silverman EM, Skinner JS, Fisher ES. The Association between For-Profit Hospital Ownership and Increased Medicare Spending. N Engl J Med 1999;341:420-426.

44. Woolhandler S, Himmelstein DU. When Money is the Mission - The High Costs of Investor-Owned Care. N Engl J Med 1999;341:444-446.

45. Duckett. Australian hospital services: An overview. Australian Health Review 2002;25:2-18.

46. Devereaux PJ, Choi PTL, Lacchetti C, Weaver B, Schünemann HJ, Haines T, Lavis JN, Grant BJB, Haslam DRS, Bhandari M, Sullivan T, Cook DJ, Walter SD, Meade M, Khan H, Bhatnagar N, Guyatt GH. A systematic review and metaanalysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal 2002;166:1399-1409.

47. Gray G. Future of Medicare under scrutiny: The Public Record 28/11/02, ABC Online http://www.abc.net.au/public/s736514.htm

48. Richardson J. Medicare: Where are we? Where are we going? Healthcover 1993;3:16-23.

49. Hall J, De Abreu Lourenco R, Viney R. Carrots and sticks - the fall and fall of private health insurance in Australia. Health Economics 1999;8:653–660.

50. AIHW. Health expenditure Australia 2000-2001. Canberra: Australian Institute of Health and Welfare (AIHW), 2002.

51. CCPA. "FastFacts" March 30, 2000. Manitoba: Canadian Centre for Policy Alternatives, www.policyalternatives.ca/mb

52. Duckett S, Jackson T. The new health insurance rebate: an inefficient way of assisting public hospitals. Medical Journal of Australia 2000;172:439-442.

53. Willcox S. Promoting Private Health Insurance In Australia: Do Australia’s latest health insurance reforms represent a policy in search of evidence? Health Affairs, May/June 2001;20:152-161.

54. Deeble J. The private health insurance rebate: Report to State and Territory Health Ministers. Canberra: National Centre for Epidemiology and Population Health, The Australian National University, 2003.

55. Smith J. Tax expenditures and public health financing in Australia: The Australia Institute, 2000.

56. Smith J. The Medicare levy surcharge arrangements: Tax penalty or hidden tax subsidy?: The Australia Institute, 2001.

57. Segal L. Why support private health insurance in Australia? New Doctor 79 2003 Publication pending

58. Hamilton C, Denniss R. Health insurance tax rort: The Australia Institute, 2002.

59. Evans RG. Chapter Two - Financing health care: taxation and the alternatives. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002:31-58.

60. Smith J. How fair is health spending? The distribution of tax subsidies for health in Australia: The Australia Institute, 2001.

61. The Medicare Bag, Medical Observer, 2 May 2003 p2, 2003.

62. Morone JA. Citizens or Shoppers? Solidarity under Siege. Special section: "Reconsidering the Role of Competition in Health Care Markets," J of Health Politics, Policy and Law 2000;25:959-968.

63. A Sydney GP who often comments on these issues in a post to the DRS website Discussion Board October 7, 2000.

64. Kron J. Dr Geoge Quittner in Social skills, News Review: Australian Doctor, 20 February 2003, 2003.

65. Neeskens P. A Script for Medicare, Guest Views: Australian Doctor, 2 May 2003

66. This and another email comment, apparently from a medical chat board, were sent by one of their authors to the DRS in late 2002. The "Con" being discussed is a long-time DRS spokesperson.

67. Grattan M. Heal yourselves, GPs urged, The Age, 11 May 2003. Melbourne, 2003.

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