Aged care has again been in the media for all the wrong reasons. Two failures are attracting particular attention.

One is the waiting time to receive aged care at home, with 200,000 people waiting in the queue. The other is the excessive charges that the government is proposing to make older people pay to receive support at home.

Support at Home is a new program meant to support older people to live at home and to prevent or delay admission to residential aged care. It was announced in 2024 along with the introduction of a new Aged Care Act. Both the new Act and Support at Home was to go live on 1 July 2025.

There are aspects of the reforms that were welcomed, especially the long overdue new Aged Care Act and the announcement of an additional 83,000 home care (Support at Home) packages. However, the government was warned repeatedly that its proposed reforms would merely patch up the system and not actually fix it and that it needed to make significant changes. It studiously ignored such warnings.

Several major problems were immediately obvious. The new Support at Home program and other major changes were dependent on the Commonwealth implementing a new IT system that would include a centralised consumer registration system, income assessment and payment claims system. This was an ambitious project even for a corporation with a good track record. It was inevitable that the Commonwealth would not have the system ready for a 1 July 2025 start date.

After being warned that it did not have its own IT systems in place in time to go live on 1 July 2025, it backed down at the 11th hour and on 4 June, it announced that both the Aged Care Act and the Support at Home program would be delayed until 1 November 2025. It blamed providers for not being ready. While it did not make it explicit at the time, this delay included the planned release of the 83,000 new community aged care packages.

Waiting for support at home

The delay in those packages caused considerable outrage and led to a Senate Inquiry into Aged Care Service Delivery. That Senate Inquiry will report on 1 October, a month before the new system is rescheduled to go live. Giving the timing, nothing in that report will change what happens on 1 November.

But the Inquiry managed to reveal the real waiting list for a home care package, something that the government had been less than honest about, and it had a powerful, if short-term, win. It discovered that more than 200,000 frail older Australians are waiting for the services they need to live safely at home. Most (120,000 people) are waiting to get assessed so they can get onto the waiting list. They are in the queue behind 90,000 other people who have already been assessed, approved and are waiting for a package. Up until then, the Minister for Aged Care and Seniors, Sam Rae, had claimed that only 90,000 were waiting and that the proposed release of 83,000 new packages would effectively solve the problem.

Before the Inquiry had even been completed, the government backed down to demands from the crossbench and the opposition for the new packages to be released. It announced that 20,000 packages would be released immediately and an additional 20,000 by the end of the year. The remaining 43,000 new packages would be released before 30 June 2026. However, given that 200,000 people are already waiting in the queue, 83,000 extra packages will not even scratch the surface, especially with the number of Baby Boomers now joining the queue.

In fact, the figure of 200,000 waiting is still a massive underestimate because it does not include people waiting for long established services such as Meals on Wheels, community transport, home nursing and other services funded via a separate program called the Commonwealth Home Support Program. The Commonwealth has deliberately never collected waiting list data for CHSP, but we know from anecdotal reports that it now also has now very long waiting lists in many regions. And this is before the baby boomers start hitting the system in any significant numbers.

While the excessive waiting list, the delay in the packages and the delayed IT system are immediate issues, they are not the biggest problems.

Support at home will be unaffordable for many older Australians

A looming problem is the massive increase in consumer payments for those wishing to stay at home. The government overturned existing policies based on the principle that fees should be based on capacity to pay. While existing consumers are protected through “grandfathering” provisions, fees for everyone else will increase the more services you need. There is no maximum cap per fortnight, which will really hit people on low incomes, renters and homeless people.

The new Support at Home payment model links fees to the number of hours of support needed per week. This unfairly penalises frailty. Those who are more vulnerable and in need of more support will face higher costs, effectively punishing them for their failing physical and mental health and their frailty. ABC Four Corners has recently highlighted this.

The consequences for individuals are obvious. The changes will have little or no impact on wealthy people and it will hit the poorest the hardest. Frail, vulnerable people will not receive the care and support they need because they cannot afford it. While there is a proposed lifetime cap on charges, this is of no use if one cannot afford to buy groceries this week and many will die long before they reach the lifelong cap.

To be fair, there is provision for a person to apply for a fee reduction because they cannot afford it. But the form to apply for hardship consideration is 17 pages long. It is clearly designed so that our most fragile citizens are not capable of completing it. This is one of many details that is at odds with the government’s rhetoric of a “rights-based” aged care system.

At the system level, excessive and unaffordable fees will inevitably force vulnerable people who want to stay at home into hospitals and care homes. It contradicts the government’s stated intention to reduce demand for residential care, will inevitably increase the number of older Australians being admitted to hospital suffering from neglect and will increase the cost of health and aged care overall. Plainly speaking, it is penny wise, pound stupid.

A fairer contribution model is urgently required. Consumer contributions should be capped at no more than 10% of a person’s fortnightly income, with provisions for fee waivers in cases of financial hardship. Like other clinical services, personal care such as showering and toileting should be free. The artificial distinction between independence and everyday living should end. It simply makes no sense to charge people a higher percentage for Meals on Wheels than for community transport.

If the Government is serious about enabling people to age in place, home care must be made affordable, equitable and accessible. No older person in Australia should be forced to choose between a meal and a shower. This is simply not acceptable in 21st century Australia.

Systemic failures

The biggest systemic failing in the government response to the Aged Care Royal Commission is its rejection of the recommendation for one integrated aged care program across both residential and home care. Instead, this government widened the gap between home and residential care and announced Support at Home.

Support at Home is a deeply flawed program that incorporates many of the worst design features of the NDIS. Under Support at Home, a consumer is approved for what is essentially a cashless credit card that they use to pay for services in the competitive aged care market. By its very nature, it turns every aged care service every day into a financial transaction. Transaction-based services work well for articulate middle-class consumers in markets where there are lots of services, where the consumer knows what they need, can pick and choose between competing services and can move to another provider if they are not completely satisfied.

But articulate middle-class people wanting transaction-based services are only a minority of those who are frail enough to require support to stay at home. The majority of people needing support to stay at home are vulnerable and open to exploitation and the majority of services they need are delivered on a one-on-one basis in the privacy of their homes, far away from regulators and inspectors. What most frail, vulnerable people want and need is relationship-based care and support delivered by people they know by name and by agencies they trust.

As it is designed, consumer co-payments for Support at Home are too high, assessment is a bottleneck and there is not sufficient capacity to flex services up and down in response to changing needs. It is inevitable that demand for both public hospitals and residential aged care will increase.

While the current government has been proclaiming Support at Home and 83,000 new packages as major achievements, the biggest achievement in home aged care is the Commonwealth Home Support Program. Despite its proven value, the government initially proposed to destroy it completely with everyone transferred to Support at Home. This was a bad decision. Sensibly, Mark Butler, the then Minister for Health and Ageing, intervened and the destruction of CHSP has now been delayed until at least 2027.

This year, 2025, marks 40 years since the Home and Community Care program was introduced by the Hawke Government. What started as HACC is now CHSP. For 40 years, it has been the only part of the aged care system that has consistently worked well. It was the funding program that allowed for the establishment and development of trusted services such as Meals on Wheels, community transport, community nursing and neighbourhood aid and these services still provide essential care for older people. It is a real Labor legacy.

CHSP provides services to more than 800,000 older people a year at a fraction of the cost of the individualised package market model. Servicing more than 800,000 people a year, it makes 83,000 new packages pale into insignificance.

In stark contrast, Support at Home is not a Labor program and is not consistent with Labor values. It is a program continued on from the last Coalition Government and is conceptually based on Howard’s “reforms” to redefine the care economy as a private for-profit market. This Coalition invention included plans to demolish both the not-for-profit community sector and programs to strengthen communities and volunteering. The eventual destruction of CHSP was part of that plan.

It is ironic that, at the same time as the Treasurer is calling for reforms to improve productivity, the government is actively working on changes that will make the aged care system more inefficient. But there is still time for the government to commit to maintaining and significantly expanding CHSP as a program that is separate to, and complements, Support at Home.

Under such an arrangement, people needing support would be given a genuine choice between a market-based transactional model or a relationship-based not-for-profit model. For older people, this would be a practical demonstration of a government commitment to a rights-based aged care system. The same services and support hours would be available in each option. The only difference would be which organisations are delivering the services and how the money flows.

For government, maintaining two programs makes good economic sense. By their design, transaction-based programs are demonstrably more expensive both for government and for providers, with significantly higher administrative, governance and compliance costs.

On the eve of the new system going live on 1 November, it is timely to question what the rhetoric of a “rights-based aged care” really means. Australia is about to implement a redesigned aged care system as a competitive private market in which you do not have a right to necessary services and, when you finally get approved for services, you may not be able to afford to pay for them.

People with the capacity to pay for their care should contribute to its cost and people with the capacity to make decisions using their cashless credit card should have the right to do so. But the role of government is to deliver an aged care system that taxpayers can afford, while ensuring that every older Australia lives as independently as possible, receiving necessary support that is affordable, equitable and safe and that ensures that every person is treated with dignity. These are basic human rights.

The views expressed in this article may or may not reflect those of Pearls and Irritations.