I see a general practitioner (GP) at a community medical service. After years of bulk billing Medicare directly for each consultation, the clinic has changed its billing model to a hybrid arrangement. Children under 15 and those with a healthcare card still have nothing to pay — for now at least! Everyone else has to pay upfront and somehow cover a gap of up to $80, depending on the length of the consultation.
There are often more gaps to cover for various diagnostic tests. My GP referred me last year to a public hospital outpatient clinic for an echocardiogram. I was warned that there would be a wait of several months due to COVID. After waiting nine months, I still had no appointment. My exasperated GP referred me to a private specialist. After half a dozen tests — some with payment gaps of more than $200 — I got a diagnosis. I had been saving to replace my 1996 car so was able to dip into these funds to cover my medical bills. Without this option I’d still be waiting.
My experience is hardly unique. A 2022 survey by HealthEd, an education company for doctors, found that 22% have recently changed the way they bill. Of those who made the switch, a third moved to a mixed model, bulk-billing only certain patients. The remaining two-thirds moved from partial bulk-billing to private billing for all patients.
The devolution of Medicare. In 1972, the Whitlam Labor (ALP) government introduced Medibank. The national insurance scheme provided free treatment in publicly funded hospitals and universal insurance to cover visits to the doctors. Medibank had its opponents within the ALP. The party policy was for a far superior fully funded nationalised healthcare system with salaried doctors. But Whitlam ignored this. The Coalition also opposed Medibank, preferring a patchwork of subsidies to incentivise those able to take out private health insurance.
When Whitlam was defeated in 1975, the new Coalition government undermined Medibank before scrapping it completely in 1981. Then with the Coalition out of office in 1983 the Hawke government re-introduced a national insurance scheme, naming it “Medicare.” It has been broadly popular ever since.
Yet Medicare is not a healthcare system, it’s a payment system. The Medicare Benefits Schedule (MBS) is an itemised list of more than 5,700 fees for services provided by doctors in private practice. In the USA, a system which operates this way would be called single-payer health insurance.
The Medicare system does not directly fund public hospitals. It covers GP and specialist visits, surgery, pathology, x-rays and other diagnostic tests. It provides a fixed rebate for each service listed. At their own discretion doctors can elect to send the account for some or all of their patients directly to Medicare. When they “bulk bill,” there is no out-of-pocket fee to the patient.
The government determines the amount of the rebate while doctors can charge what they choose. While rebates are periodically adjusted, the amount has steadily declined. A standard consultation currently attracts $39.75, which is one-fifth less in real terms than it was when Medicare commenced.
In 2013 the ALP froze the Medicare rebate in what it called a “temporary budget measure,” part of a $664 million savings plan. After the ALP lost that election, the new Coalition government pushed to introduce a co-payment for everyone bulk-billed. This proposal sparked mass grassroots opposition. The government eventually abandoned the plan, instead launching a financial assault on Medicare by extending the rebate freeze. The freeze remained in place until 2022, when the rebate increased 1.6% at a time when the Consumer Price Index increased 6.1%. Clinics need to fund all costs, including rents, utilities, equipment, medical supplies and wages.
Hands off Medicare rally on 11 January 2014. Photo by FSO.
System in crisis. It is getting more and more difficult for people, even those with a healthcare card, to find a GP who bulk bills. There is a growing GP shortage, and wait times for appointments are blowing out.
These factors are spilling over and impacting on the public hospital system, already overtaxed by COVID. Patients unable to see a GP are turning to overcrowded hospital emergency departments where burnt-out workers are stretched to breaking point. Paramedics are also bearing the brunt. It has become commonplace to hear reports that the ambulance system — overwhelmed by demand — has called another Code Red, meaning that there are no available ambulances! Images of queued ambulances waiting to discharge patients at emergency departments are often in the news.
Regional and rural Australia is currently the worst hit by the growing health workforce shortage. More than 15,000 patients in Mildura were left without a bulk-billing doctor after their clinic closed last year. In Bairnsdale, all clinics have closed their books to new patients and there is a four-week wait time for a GP appointment.
Lack of access to healthcare impacts life expectancy. The Australian Institute of Health and Welfare reports rates of potentially preventable hospitalisations that are 2.5% higher than in the city. When it comes to cancer care, those in rural areas have a 7% higher mortality rate than those in the cities. For First Nations people, unequal outcomes are worse, especially for those unable to easily access an Aboriginal Community Controlled Health Care Organisation (ACCHO) providing culturally safe care.
Staff shortages are also impacting basic hospital services in rural communities. A shortage of midwives and obstetricians resulted in the western Victorian city of Portland suspending maternity services. In Carnarvon in Western Australia, pregnant women now have to travel 470 kilometres south to Geraldton, or even further to Perth, after the local maternity service shut its doors.
Reproductive health services are increasingly hard to access. The 16th National Rural Health Conference last August heard that one in three Australians live in a region where there is no access to medical abortion. Only 10% of GPs have completed training in medical termination, and Marie Stopes closed its regional reproductive health clinics in 2021.
Government provides various incentives to attract GPs to practice in regional communities. Such programs will only make a modest difference in the context of a declining GP workforce. The General Practitioner Workforce Report prepared by Deloitte in 2022 predicts a 28% shortfall of GPs in the next 10 years, impacting major cities as well as regional communities. Late last century, the majority of Australian doctors were GPs. But not anymore. The percentage of medical graduates choosing general practice has fallen to less than one in five.
Providing medical care is becoming increasingly corporatised. Most GPs do not own their own practice, instead working as part of large practices with six or more GPs. In 2022, just 25% were practice owners and when surveyed, 60% of non-owner GPs said they were not at all interested in becoming practice owners — suggesting they were more interested in providing primary healthcare than running a business.
Strengthening Medicare. Elected last year, the Albanese Labor government established a Strengthening Medicare Task Force to advise the government on what is needed to solve the battered primary healthcare system. The Task Force, chaired by the Health Minister, will make recommendations about how to spend the $250 million of additional funding allocated each year for the next four years.
The October budget included some one-off grants to GP practices for training, equipment and minor capital works, but did nothing to repair the damage caused by the long rebate freeze.
Last month, the Grattan Institute released a report, A new Medicare: strengthening general practice, offering its advice to the Task Force. It makes welcome criticisms of the current model, which does not provide holistic care to those living with chronic diseases. It slams the fee-for-service approach to funding as one which incentivises speed rather than quality of care. It recommends major changes to how GPs are paid, replacing it with a model where GPs are funded to work as part of multi-disciplinary teams and are able to provide more time to those in greatest need.
While it is welcome to see significant patient-centred changes as part of the public discussion, we need a system that delivers equal access to high quality, holistic healthcare for all. This means taking profit out of the equation.
Defend, extend and transcend Medicare. Medicare, as it operates today, is threadbare. Here is what is needed immediately to address the most gaping issues and also extend Medicare:
Everyone — regardless of their visa status, where in the country they live, or whether they have a healthcare card — needs timely access to a bulk-billing GP. Increasing the rebate for all MBS items to address the years they were frozen is essential to help address this.
Medicare must be expanded to provide uncapped access to mental health services and to add dental and allied health services to the mix.
Open publicly run GP clinics, staffed by salaried workers, starting with outer suburbs and rural areas where the supply shortages are most acute.
Prioritise workforce retention and planning. Increase pay for current healthcare workers. Attract more students to study medical, nursing and allied health courses by providing scholarships and scrapping all tuition fees for those who take up positions working in priority areas when they graduate.
Consult with Aboriginal Community Controlled Health Organisations to revamp the current patchwork funding model. Provide long-term funding security that will support holistic and culturally appropriate ways of working.
Mandate the provision of reproductive health services for those accepting public funding. All pregnant people must have choices, including birthing choices. Boost funding for more birthing on country and for holistic maternal, child and family services.
These changes would make a huge difference when it comes to accessing primary healthcare. But ultimately, the system will still be plagued with problems as long as profit rules.
One industry that is raking it in is the private health insurance industry. Last year the industry, which receives $6 billion in tax payer subsidies annually, made $2 billion in profits — doubling what it made the previous year. Another is the health giants selling medical devices who are estimated to receive $625 million in subsidies from the Australian government — which is more than they pay in tax. Imagine what these subsidies could achieve if they were redirected into public healthcare.
To get the free, holistic, high quality universal primary health that we deserve, we need a system driven by different priorities. Let’s nationalise the entire healthcare system — frontline care and hospitals plus the production of pharmaceuticals and medical devices. With this kind of system, where health workers in conjunction with patients, make the decisions, we won’t need insurance anymore — private or Medicare. Healthcare will be a right and it will be free. But until we can transcend Medicare, it is a system we need to defend, extend and deliver for us all.
