Fair access to health care is in the zeitgeist of European countries and Australia. The political sensitivities of this issue were demonstrated in the last election with the angst generated by the Labor Party’s “Mediscare” campaign.
The closest we get to equitable access in Australia is through Medicare – especially bulk-billing – and our public health and hospital services. Do those with health needs get access to the treatment their conditions demand irrespective of their ability to pay?
Tasmanian Labor Senator, Helen Polley, asked the crucial question of health officials at the recent Senate Estimates hearings, “..from your point of view it might be services, but from a patient’s point of view, if you are looking at Tasmania or WA and the ACT, it is the community who have issues about not having access to bulk-billing.”
This is the central question, whether Medicare ensures equitable access to primary health care. This is more than services delivered; it is about needs. Administrative data can give some clues about things amiss. An average Australian visits a GP about 5 times per year and consults a specialist once a year. Whereas in the Northern Territory and ACT there are 3.5 GP visits a year suggesting barriers to access in the NT and that ACT people are more healthy or use private health insurance.
Two thirds of patients had all their visits bulk-billed in 2015-16; one third had added costs. RACGP and AMA presidents seized on these data to say that bulk-billing rates were a casualty of the freeze on Medicare rebates with patients paying higher ‘out-of-pocket’ expenses – the RACGP’s estimate – $48.69, and AMA’s – $34.61.
Overall more patients are having some services bulk-billed but this is a wrong measure of access to GPs. As noted in an earlier blog, “A categorical mistake: Is bulk-billing a reliable indicator of access to GPs?” (9 June 2016), which quoted the RACGP’s Expert Committee on Quality Care, “The very high and frequent GP attenders are more likely to be older, have multiple chronic diseases and live in areas with the most socio-economic disadvantage. These 12.5% of patients are the ones who significantly account for much of the bulk-billing figures, which leaves the majority of the population with much lower rates of bulk-billing.”
Also MBS items are used to fund a wider range of primary health services than provided by the GP alone. This bulk-billing supplements the base funding of a range of health organisations enabling access to a wider range of front-line services.
What we don’t know: Can people find a GP who will bulk-bill and be prepared to see them? Can the patients afford the out-of-pocket expenses? My colleagues and I believe the answer to this question is, too often – no.
Medicare is the best community health cover we’ve got. For all its faults, especially fee-for-all-services, it is worth fighting for, especially for bulk-billing GPs.
I’ve watched the ups and downs of Medicare. It started with Bill Hayden trying to sell Medibank to halls packed with hostile and angry doctors. And from when, late one afternoon, five Doctors’ Reform Society doctors met with Ralf Hunt, the Fraser Government’s health minister, to oppose the abolition of the earlier Medibank and bulk-billing.
Minister Hunt listened thoughtfully and was palpably taken aback by what we had to say. He said,” How do you explain that I have met with the full executive of the AMA this morning, and, to a man, they fully supported the Government’s plan to abolish bulk-billing?” We said, the AMA did not speak for us or our patients. To his credit, and in our presence, Ralf Hunt tried to think through how the Government might change its direction.
Thus, in 1976, was born Medibank Mark II, which through the Fraser years had its remit challenged repeatedly. Which meant, at the start of the Hawke Government, that health minister Neal Blewett, had a fight on his hands. With the support of the Democrats and moral support of some in Opposition, such as Peter Baume, a re-invigorated Medibank – Medicare – was passed by a difficult Senate.
How different it is today, with the AMA, RACGP and much of organised medicine standing firm in defence of bulk-billing and Medicare.
It was worth fighting for; it is worth fighting for.
Ian Webster is Emeritus Professor of Public Health and Community Medicine UNSW.