The Prime Minister, Mr. Howard, has suggested that Medicare bulk-billing should be limited to those in special need. For six years the Federal Government has been asserting, from time to time, that Medicare is not for the rich, that Medicare is or should be a safety net, that those with good incomes should fly Business Class, go private and not use Medicare. Young people were told to "run for cover" with private health insurance lest bad things happen twenty or thirty years hence, when all the while they had cover under Medicare anyway.

Yet underneath Medicare, as proposed twenty years ago, whether it covers public hospitals or general practice, is the principle of universality which applies both to its support through taxes and its use by everyone. This means that Medicare funds care for all those who choose to use it according to their need. Universality takes seriously the reality that sickness and accidents happen chaotically, that suffering is largely undeserved and that a humane and caring society wishes all its citizens to have the same access to care according to need and unrelated to their financial status. Why change it?

The struggle to understand the latest proposed changes to Medicare, to make it fairer it is said, is due partly to the lack of an acronym. So I propose the word Forcenet – Fee-For-Service with Computerized Safety Net – to capture the main elements of what the Federal Government is aiming for. If Forcenet has a military ring to it, that may be no accident. Forcenet could easily be part of future battles to defeat the Axis of Evil if the Axis can be stretched to include social welfare in any form. If Forcenet reminds you of arrangements to eradicate the unemployed then you, too, might be close to the truth. Under Forcenet, charity is back in fashion.

Where did Forcenet come from? Forcenet’s origins are not hard to fathom.

First, as John Ralston Saul, a Canadian social commentator, has suggested in The Unconscious Civilization, governments can make beliefs like ‘publicly funded health services cannot cope’ come true simply by inadequately resourcing them. The current government does not like publicly funded services and believes that private services are better. They are setting about doing what Saul discusses – starving the public system to prove that the system is weak. This manifests in Medicare not keeping up. In self-defence and urged on by strident professional groups, general practitioners increasingly are charging more than the standard fee for their services. The amount they receive through Medicare for each patient visit has not, in their view, been adequate. They do not feel this situation will improve, in fact they believe things are getting worse. In consequence their fees have risen faster than Medicare rebates. Patients are paying more for general practice consultations.

In reality, from a financial point of view, Medicare is fully sustainable by our economy for the foreseeable future. More money for Medicare could be drawn from the $3 billion returned to private health insurance holders through the 30% private health insurance rebate. There is no financial crisis.

Medicare is one of the affluent world’s most economically sound systems of paying for health care and it is economically irrational to propose a regression to private funding. Also, while it is fashionable to claim that the ageing of the population will break the bank, the fear of an epidemic of Medicare-consuming octogenarians is misplaced. But the "Grey Peril" myth serves a useful political purpose. It enables politicians who want for other reasons to demolish the public health care system and replace it with a P-76 model of charity and private practice – Forcenet - to scare us. We should ask for the facts.

Second, and associated with the first cause of Forcenet, the proportion of visits to general practitioners that incur no cost to the patient is falling. Direct billing of Medicare for consultations has fallen from a high of 80% of all general practice visits in 1997/98 to 68.5% now. John Deeble, one of the architects of Medicare, showed figures at a recent seminar of the Australian Health Policy Institute (AHPI) at the University of Sydney that reveal that the decline in direct or bulk- billing of Medicare has gathered pace in the past two years. Those patients needing their doctors to bill Medicare directly suffer as bulk-billing ceases. Some sort of safety net is required to reduce this political threat.

Third, there are growing dissatisfactions with out-of-hospital Medicare. These are both specific and general. Specifically, it does not cover physiotherapy, dental care or the organization of care needed by older people with continuing health problems. A lack of general practitioners in the bush might be resolved in part through different Medicare arrangements, although Gordon Gregory, from the National Rural Health Alliance, told the AHPI symposium that the Coalition’s proposed changes to Medicare cannot be justified on the basis of what they would do for rural Australia. These other aspects of concern with Medicare should be addressed and dealt with separately.

Both the federal Coalition and Labor parties offer solutions to the problems with medical Medicare. The Coalition response, as Deeble tells it, would increase general practice incomes by between $300 and $400 million a year, two-thirds to three-quarters of this amount coming from patients paying more, thus strengthening fee-for-service medicine. The Labor proposal would increase general practitioner incomes by a similar amount by increasing Medicare payments. Whether this increase in general practitioner income is enough to influence bulk-billing we do not know.

Forcenet loosens government control over the price of general practice care and expects users to pay more directly at the time they visit general practitioners. It restricts bulk-billing principally to health benefit recipients and pensioners. Non-pensioners will pay more for each consultation although some of this co-payment can be claimed back from private health insurance. General practitioners will receive more for treating non-pensioners than for pensioners. This may influence the quality of care. Figures from Melbourne health economist Jeff Richardson demonstrate that, already, private patients are two to four more times likely to have coronary artery repair procedures after a heart attack than public patients.

Labor’s proposals maintain Medicare as an instrument of national government in relation to health care. Neither Coalition nor Labor proposals go beyond the boundary of medical Medicare. Both parties leave the concerns of patients for more comprehensive and coordinated care unmet. How efficient are the two proposals?

As Jeff Richardson points out, for a health service to be efficient, it must first do what we want. Flying to Canberra economically when you wish to be in Melbourne is not efficient.

What do we want? The Coalition proposes to change a public system into a user-pays-plus-safety-net system. Is this what we want? The Opposition is offering more of the same Medicare. Is this what we want? These questions should be put to the community and discussed.

Be all that as it may, the consequences of moving from Medicare to Forcenet can be seen right now. There’s no need to dig like an archaeologist down to our picket fence era to unearth our own pre-Medicare Australian version to find out what they might be.

Instead, visit me in New York and I’ll show you how it’s possible for just such a health system, admittedly with its pockets of excellence, to cost twice as much as ours, to have 10% of the population without health insurance, to have families bankrupted through health care costs, and to have an underclass with life expectancies 10 to 20 years less than the wealthy.

Return to issue 79 index

[ Doctors Reform Society of Australia home page]
[ About DRS ] [ Search ] [ What's New ]
[ Policies ] [ Media Releases ] [ Published Letters ]
[ Online articles ]
[ New Doctor: Journal of the DRS ]
[ Discussion Board ] [ Contacting DRS ] [ Joining DRS ] [ Links ]