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Prime Minister John Howard once said he wanted to make Australians more relaxed and comfortable. Instead, research suggests we are becoming more alert and alarmed. This is not surprising. We have experienced relentless reforms to reduce job security, income security and public services coupled with international posturing raising our profile in the eyes of terrorists and harming our relationships with nearby countries.

Despite this, Howard remains popular. Even his lies do not stick (although at least you don’t hear him called "Honest John" anymore). He seems unscathed by numerous bald-faced non-core promises and logical inexactitudes: there’ll be no GST, children were thrown overboard, Iraq’s weapons of mass destruction necessitate immediate war, we support Medicare... the list goes on.

Howard’s vision is of an Australia with less community and more individual responsibility. Naturally, this vision suits "strong" individuals - namely, the wealthy and powerful. Universal cover by Medicare and public hospitals irritates Howard because this means health care is a community responsibility. He must find it irksome that people who do not consciously plan for their own health care are still able to receive it. The Federal Government has been slowly strangling Medicare and public hospitals for years. Yet Medicare’s continued popularity means an imaginative approach to the facts is required to shift public opinion.

Howard recently claimed that he is not eliminating our universal health system because Medicare, and specifically bulk billing, was never universal. There is a history behind this (also discussed in our Flashback to 1980 reprint, pp 28-32). Although bulk-billing was never universal this was arguably due the actions of conservatives and doctors in the 1940’s when a federal Labor government passed legislation to provide a range of 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. In the longer term, a legal challenge or another referendum to remove this clause may be required to resolve these issues.

Howard claims his Medicare changes will support bulk billing. In reality, his recently revealed "Fairer Medicare" package makes it both easier and more attractive to stop bulk-billing people. He also says his package will improve access to health services. Yet the 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.

Primary care is the most important sector of any health system. In Australia at present, it does seem more money will be required to fund GP services. The government and AMA claim that to financially survive GPs need $50 per visit. This mutually convenient figure allows a calculation that raising the GP rebate to increase bulk-billing would cost billions. It needs to be understood, however, that this figure of $50 arose from a suspect relative (not absolute) value study which assumed that specialist doctors are not overpaid. In reality, the government could probably have cemented bulk-billing during 2002 by raising the standard GP consultation rebate to $30, increasing the income of a typical GP by about $40,000 a year and costing around $400 million. Thanks to government action and inaction, GPs are increasingly disgruntled. It could now prove far more costly to increase bulk-billing.

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. The Federal Government cries poor when funding Medicare, public hospitals and subsidised medications, indicating that the costs are becoming too great for any government to bear. Yet the government happily pours ever increasing billions into the private health system. The Federal Health Minister, Kay Patterson, publicises figures indicating that the Private Health Insurance Rebate costs 25% of the Medicare Benefits Schedule, 30% of Federal public hospital funding and 44% of the Pharmaceutical Benefits Scheme because she believes they prove the PHI rebate is not expensive (The Age, Letters 17/4). Amazing but true. Though perhaps her lack of perspective is unsurprising. Federal Health Ministers of all political persuasions have been receiving complementary copies of New Doctor for decades. Kay Patterson’s office is the only one to have returned theirs, complete with a note saying to never send another.

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, particularly families, 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. This system fails in the United States and has failed previously in Australia. The universality of Medicare needs to be salvaged and the services it covers extended. Private fee-for-service medicine looks difficult to dislodge but we need to continue the push to reduce our system’s reliance on it. Now is a critical time to make our voices heard.