Dr Rachel David spoke with 2GB on the 40th anniversary of Medicare

Station: 2GB
Program: Afternoons
Date: 1/02/2024
Time: 12:35 PM
Compere: Michael McLaren

Interviewee: Dr Rachel David, CEO, Private Healthcare Australia


MICHAEL MCLAREN: Well, today, 1 February is a big day for our health system because, as you would have been hearing all week actually, it is the 40th anniversary of Medicare. First launched 1 February 1984. Some will remember all of that. But like all of us, I think, that use the system, as Medicare has aged she’s shown some signs of that ageing. The scheme is challenged by an ageing population, expensive modern medical equipment and also, obviously, federal budget constraints.

Now, in the ’80s, Australia’s health profile was very different to now. We forget this, but our life expectancy was around a decade shorter 40 years ago, part of that because smoking was more prevalent. But you see, these days we’re living longer and a lot of that’s thanks to medication. But obesity is a bigger problem now than, for example, in the ’80s. So there are a lot of moving parts here. And 40 years on, I think we should examine how healthy Medicare is itself, what’s working, what’s not.

Well, on the line the CEO of Private Health Australia [sic], Rachel David, and I’m speaking to Rachel deliberately because one of the strengths of the Medicare system, compared to some other public health systems around the world, ironically, is that Australia still has a relatively robust private system that takes some of the strain away. Rachel David’s on the line. Rachel, good afternoon.

RACHEL DAVID: Good afternoon, Michael.
MICHAEL MCLAREN: Some would say, okay, you’re talking about public health here, but you’ve got to guess from the private health sector on what’s going on. But as I’ve just explained, you take the private health sector of Australia away and Medicare rapidly starts looking like Britain’s NHS, doesn’t it?
RACHEL DAVID: Well it does, it would be really like toppling over dominoes to take the private sector away in Australia. And I think if you look back to what Neil Blewett and Bob Hawke designed in 1984, the private sector was incorporated into that design as a deliberate feature of the system. Because they had the vision to realise that Australia needed that choice, flexibility and the ability to attract doctors into a vibrant system.

It’s served us really well over the years and people should be really grateful that Australia, the Australian health system that we have, gets some of the best health outcomes in the whole world. Some of the worst health outcomes in the developed world are in the US and the UK, in the NHS, which have systems that are either very inequitable in the US or incredibly inflexible, which is the UK where you have long wait times and very little choice about what doctor you see.

MICHAEL MCLAREN: And, the benefits are then shown in the statistics here about life expectancy and liveability and recovery from preventable diseases and causes here compared to the UK in particular. The numbers suggest our system is more fit for purpose than theirs.
RACHEL DAVID: Absolutely. And, really, we have a lot to be thankful for that our system’s been kept- kept those great outcomes pretty affordable as well. And as a result, people might not realise, we’ve gained an extra 10 years of life on average since 1984. And look, a lot of that’s due to public health measures around smoking and so forth. But it’s also due to the fact that it’s easy and affordable or, you know, it has been to see a doctor. So, people really need to be- to kind of understand that we can count our lucky stars in this country compared to living anywhere else.
MICHAEL MCLAREN: Just on that point about seeing a doctor, I mean, that is another part of the whole Medicare story – bulk billing and the like – but I was reading, in fact just today before speaking to you, a piece in The Australian saying that ambulances are now taking as long as 55 minutes to reach the most urgent cases in one state; the number of people who cannot afford to see a doctor has doubled nationally just in the past year; those bulk billing rates are coming down. There’s a range of reasons why that happens to be but it is indicative, 40 years on, the old girl is under a bit of pressure.
RACHEL DAVID: Yes, that’s right. And everybody needs a mid-life health check. But I think also we’ve got to remember we have had a massive health care and economic shock in the pandemic, and it’s going to take the system a while to recover. In the meantime, there are some things I think the government, as well as the health providers and stakeholders need to look at. And probably the most urgent thing is how much people really are paying to see a doctor.

We all know that some of the bulk billing statistics and some of the statistics that have been quoted by the government in the past have been, let’s say, perhaps a bit exaggerated over the years, and that if you actually ask patients what they were paying to see the doctor, those statistics would look a lot more, a lot more rubbery. I think the current minister has done a couple of things to fix this up but, you know, the reporting on GP bulk billing has got a lot more accurate.

And there’s been a tripling of the bulk billing incentive, which is a thing where GPs get paid more to bulk bill sick and vulnerable patients, which has been a really big step forward. But I think, across the board, the Commonwealth needs to get a lot smarter about how it measures what patients are actually paying, and that means not just using the official statistics, but actually doing surveys to keep track of it. And one of the reasons that we say that is, it’s absolutely obvious from our data and from some of the patient complaints that we’ve had to follow up, that unfortunately, some medical practices are bulk billing and then charging patients a separate fee through a different system, which is not legal, but it does happen.

And we’ve also seen a kind of- a really kind of rapid explosion in out-of-pocket costs that has occurred as a consequence of inflation…

RACHEL DAVID: …following the pandemic. And we really do- including a lot of extra charges that are unrelated to medical care. And we’ve really got to keep an eye on that.
MICHAEL MCLAREN: Let me ask you, because we are doing a retrospective of sorts here on Medicare 40 years on. But what was Australia’s healthcare system like before Medicare? Why did we bring it in? What was the justification?
RACHEL DAVID: Well look, before then you did have the ability through either personally or through some of the associations to have private health insurance. And often what would happen is that doctors or hospitals would decide to- if you were struggling, they would decide to provide you care free of charge.
RACHEL DAVID: And there were- and so you- and there was a sort of a deductibility for health insurance through the tax system. But as you can see, that kind of system meant that people really missed out. And the Commonwealth a few years before the introduction of Medibank, then Medicare, had taken a big step forward and fought a big constitutional case to introduce the PBS so that people could get- which is the Pharmaceutical Benefits Scheme so that people could get access to cheaper medicines. And I know in my family my grandma, who was a war widow and her son was very, very sick, and the introduction of the PBS actually saved his life because even as a war widow, she couldn’t afford his medications. So it was pretty rough up until that point. And you certainly had people begging, borrowing and stealing to be able to access appropriate Medicare…
MICHAEL MCLAREN: [Talks over] For those in the middle of the financial story, though, did Medicare dis-incentivise private health? Because the old anecdote, anyway, was the first thing everybody did when they got their very first paycheque, no matter how big or small it was, they went and got private health cover, whatever they could get, because without your health you got nothing. Whereas- well, as soon as Medicare arrived, that incentive may well have been taken away for some. Is that true, or is that anecdote only?
RACHEL DAVID: Look, that was true for a while. But I think the system has evolved so that private health insurance and Medicare coexist actually as part of the same system, because what they’re doing is- what private health is doing at the moment is it’s funding the lion’s share of planned or elective surgery. That means that the public hospitals don’t have to put those people on waiting lists. But that’s really become its main purpose, along with two other things. And that’s funding most of the inpatient mental health care for anxiety, depression and addiction, and also funding dental care. So that is where private health insurance has found its footprint. It means that public hospital waiting lists, although they’ve blown out again recently, are manageable for the government. It’s kept the costs of dental care much lower than they would have been had it not been in the system. And it’s really been a failsafe for people that have required prolonged treatment for mental illness because of an addiction or an eating disorder or anxiety or depression. It’s provided a failsafe for those people to have a prolonged admission, which is just not possible in the public system at the moment.
MICHAEL MCLAREN: Just before you go, just one last one. We could talk forever, but obviously time doesn’t permit. But you do mention dental. Now, many have said that the great weakness of the overall Medicare and public health system is the lack of availability of dental. There is some, but it isn’t ubiquitous, obviously. What’s your comment on that?
RACHEL DAVID: Look, I think if there is to be Commonwealth or further funding for dental care, it needs to be very well targeted. A universal dental DentiCare type of scheme, similar to what we do for GPs, would be phenomenally expensive, particularly if the payments were not capped in some way. And it would- again, because most dentists do live and practice in the wealthier urban areas, it would predominantly favour the wealthy. And what I think we’d see is a very skewed system come in place. So I think we’re doing very well with keeping the cost of routine dental care down through a combination of private health insurance and some government funding. But if government funding is going to increase it should be in a targeted way and not across the board.
MICHAEL MCLAREN: Because there is that argument, isn’t there? You know, a lot of the diseases, a lot of the problems from a health point of view start in the mouth. But if we don’t incentivise people to get their teeth checked, they don’t go to the dentist and they don’t- those small problems become bigger medical problems that are then attracting Medicare one way or the other as they move to other parts of the body. And maybe, if we nipped it in the bud early – yes, spent the money up front on dental – we’d be saving down the track on other what could have been preventable diseases. I suppose you need an actuarial mathematician, though, to work it out, wouldn’t you?
RACHEL DAVID: Well, look, what I think there is room for is looking at how people that are experiencing significant disadvantage are able to access dental care, particularly preventive dental care. So having teeth professionally cleaned and inspected and so forth is within the reach of most people. And that is certainly something that health funds have been able to pay for and encourage people to do. But for people experiencing significant disadvantage, absolutely. Problems that start in the mouth can cause lifelong chronic disease, and that is where the government should be looking if they’re intending to make a further investment for dental, is to assist that group. If you start talking about a universal scheme, I can guarantee right now where all of that money will be going, and it will be into wealthy inner city postcodes, because that’s where the majority of dentists are set up in a practicing, and it won’t touch the sides of the disadvantage problem.
MICHAEL MCLAREN: It’s wonderful to talk, thank you for your time. Thank you for your insight, Rachel. Much appreciated.
RACHEL DAVID: No problem at all.
MICHAEL MCLAREN: That’s the CEO of Private Health Australia [sic], Rachel David.
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