Health policy reform is difficult. There are an abundance of powerful stakeholders whose number one priority is definitely not optimum health care for all Australians. But most Australians do share the view that our health care system (which isn’t really a system) needs improving. There are two broad aspects to optimising health. The first is equitable timely access to high quality care. The second is addressing all those factors outside the health system which affect health. These are the social determinants of health and of productivity. Healthy people are more productive. The key social determinant is income inequality, both absolute and relative.
Social Determinants Now
What could be done immediately following next month’s election to improve health and productivity? A good start would be an immediate increase in the Newstart Allowance by $75 from the current level which is 40% below the poverty line. From the Australian Council of Social Services (ACOSS) to the Business Council of Australia there is a call for such an increase. The only significant group of people who seem to be resisting the idea are politicians. It would send a clear message to Australians that punishing the unemployed is not right. It could easily be sold as both a health and productivity measure. Nearly a million Australians struggle on this inappropriately named ‘welfare’ payment.
But income inequality as a determinant of health and productivity is not confined to those on Newstart. Relative income inequality, the difference between those on $40,000 and those on $4 million also makes a difference. The degree of income inequality in wealthy nations correlates very well with measures of health and social problems. Australia ranks well above average in terms of income inequality in OECD countries (ACOSS Page 31). Productivity is threatened by the degree of income inequality, according to economists from the International Monetary Fund. It therefore makes sense to have tax reform which attempts to redress the trend to greater inequality which we see in Australia over the last 15 years, particularly with respect to wealth (ACOSS Page 22). Labor is to be commended for moving in the right direction.
What else could be done almost immediately? Fourteen percent of sick Australians on below average incomes delay or don’t fill prescriptions because of cost (Commonwealth Fund 2014 Page 24). Many of these drugs such as cholesterol lowering agents and blood pressure tablets save lives. That is why they are subsidised. The Federal Government whether Labor or Coalition imposes co-payments, which are essentially regressive taxes on illnesses. It’s time to reduce these co-payments so that no one misses their medications because of cost. This can be done immediately.
Access to specialist is also a problem. Patients either don’t see specialists when they should, go broke seeing specialists who have scant regard for their patients’ financial and therefore emotional well being, or wait months to years to see public hospital specialists. An immediate quarantined funding of specialist public hospital outpatients would change all that and patients with the full spectrum of diseases would benefit. This is in contrast to the focus on cancer patients outlined in Labor’s discriminatory cancer policy plan. However Labor is to be commended for its proposal regarding specialist public outpatients even if little detail has been given.
There is an Aged Care Royal Commission. Last year an inquiry into a proposed bill on aged care staffing recommended publication of staff ratios and a minimum of one registered nurse on duty all hours. Then the Government effectively stopped governing as it didn’t feel it was in control of Parliament. The recommendations and the bill are therefore awaiting a new Government. The recommendations are a first step and could be implemented immediately.
Hospital funding is a perennial issue. Labor has now promised a return to matching the States for the costs of running public hospitals, the so called 50:50 split. It is unclear whether this refers to new funding or to total funding. Their policy when last in government related to new funding which means it will be a decade or two before Federal funding matches State funding. Nevertheless, it is also a first step.
The Long Term
However, these issues and many others reflect the chaos of our so called health system. There is no overarching vision of how our health system should work. Politics in a federated system means chaos, division, the blame game, and lost opportunities.
A Productivity Commission assessment of private health insurance (PHI) has been proposed by Labor. It is welcome if and only if it is asked to address the efficiency and equity issues relating to taxpayer funding of PHI. Otherwise it is an exercise in futility designed only to benefit those who can afford PHI, whilst ignoring the rest of the population.
Labor has suggested a permanent Health Reform Commission but its proposal lacks two essential ingredients, if such a commission is to provide a way forward. The Commission must be independent of all the stakeholders whose prime interest is not patient well being as proposed on this blog. These include governments, the Australian Medical Association, the Pharmacy Guild, and the pharmaceutical, private hospitals, and private health insurance industries. It must have power to implement suggestions as I have described previously. Thus if it initially is responsible for all new health funding, it can distribute that funding to where it is needed by patients, not to where it is politically advantageous, or to where it will placate a powerful provider lobby group. Over time it could rationalise and assume responsibility for current funding. An advisory body will be ignored whenever the advice does not suit.
Such a body can then grapple with the many major gaps in service provision which include dental care, mental health reform, primary health care, prevention, and Indigenous health. It can also address the major problems of poorly integrated care and direct funds to where evidence shows it may work. It can fund the collection of data which is essential for its own work. It can point the way to addressing the social determinants. The issues are well recognised.
Whilst politicians cling to the same way of doing things as they have to date, we will not see the improvements in our health system which are possible and which every Australian deserves. The suggestions above can be sold as a way to increase health and increase productivity, which would appeal to almost all Australians. Can a progressive government grasp the opportunity and step forward with a new way of getting complex change to occur in a federated system riven with powerful lobby groups? We live in hope. We hope for our patients.
Dr Tim Woodruff is president of the Doctors Reform Society, an organisation of doctors and medical students promoting measures to improve health for all, in a socially just and equitable way. On twitter @drsreform