Health Budget 2016-17 – the reality television guide

It was always going to be a difficult Budget for Prime Minister Malcolm Turnbull with challenges on both political and health policy fronts.

Traditionally, the first Budget of a government’s term in office aims to establish its economic credentials, usually by cutting programs established by the previous regime and arguing the need to pay off debt and increase government revenue.

The second Budget typically consolidates these cuts, deals with any minor outstanding issues, and puts the government into a holding pattern until the third, pre-election Budget. This is when the government draws on the (now expanded) revenue base, to deliver what it hopes are vote-winning tax cuts and funding promises.

However, having taken on the leadership of the Coalition so late in the political cycle, Malcolm Turnbull finds himself in the tricky position of having to simultaneously deliver a first and third Budget, i.e. one that demonstrates both his fiscal restraint and expansive economic and social policy vision.

This is made even harder in the health portfolio as the Prime Minister has inherited the fall-out from the ‘slash and burn’ 2014-15 Budget which destroyed a number of health organisations and programs which could have assisted him in achieving policy gains in this area.

In addition, the Government is having a particularly bad PR moment in the health sector, facing ongoing negative campaigns from a number of key groups including those representing pathology companies, GPs and medical specialists over the failure to increase Medicare rebates. It is also currently caught in the crossfire of a stoush between private health funds and medical technology companies over prostheses funding.

Turning this situation into a win for the Government will require a carefully orchestrated performance, combining a juggling act to manage the competing priorities in this portfolio with some clever political manoeuvring and expert spin doctoring from the Government’s advisers and strategists.

It’s a Budget Night that promises to deliver all the tension and spectacle of a TV drama albeit one which has ‘real life’ consequences for both participants and viewers.

With that in mind, Croakey has drawn on the tradition of the reality TV show to provide the following guide to some of the likely tactics and techniques used by governments at Budget time and to make some predictions of what we can expect tonight in Budget 1016-17.

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Jennifer Doggett writes:

Renovation rescue

All governments are keen on a policy renovation rescue when the opportunity arises. After all, why create something from scratch when you have inherited a basically sound policy or program? Even if it is a little shabby and dated by its association with a previous government, re-developing and updating an old policy or program is usually easier than coming up with something completely new. Plus there is the added bonus that you already know what the electorate thinks of it so you can avoid any nasty surprises down the track.

Generally the renovations involved are more cosmetic than structural: change the name, tweak the language, use the opportunity to put some ‘friendly faces’ on a relevant Steering Group or Board but basically leave the underlying structure intact. For example, Divisions of General Practice to Medicare Locals to Primary Healthcare Networks.    It’s amazing how many different primary health care programs can be ‘created’ out of what are essentially the same organisations, with just a bit of window dressing.

Prediction: There are a few potential candidates for a ‘policy renovation rescue’ tonight:

Mental Health policies have been focussing for decades on improving the identification and care of people with mental illnesses in the community. Yet despite the myriad of strategies and policies on this issue, people with mental illness still struggle to access the care they need for both mental and physical health problems. Late last year the Government committed to addressing the recommendations made by the National Mental Health Commission ‘‘within the existing funding envelope“. Given the level of unmet need that still exists in the community for mental health care, tonight might be a good time to open the envelope a little bit further to fill in the gaps and link existing services to deliver a genuinely comprehensive system of care for the approximately 3.2 million Australians likely to experience a mental health problem this year.

Also deserving of an update and new coat of paint is the preventive health agenda, which has been largely dormant since the demise of the Australian National Preventive Health Agency. Its goal to reduce harms resulting from alcohol, tobacco and obesity could be re-visited in the context of the current debate over a sugar tax. A new but expanded preventive health strategy would allow policies to move away from the narrow substance/behaviour specific approach to prevention in order to focus on the underlying drivers of health inequity, such as poverty and discrimination.

Risks: As in Renovation Rescue, ‘policy rescue’ can be easier in theory than it is in practice, particular when there are some fundamental problems with the original underlying structure. Ongoing attempts to plaster over the deficits within our health system, such as our reliance on a fee-for-service funding mechanism, can result in cracks which gradually widen until they eventually destabilise the entire structure.

The Bachelor

It’s hard being the Health Minister when there are so many attractive causes competing for your attention. Budget time is particularly stressful with all the eye-catching and ambitious chronic disease groups hanging around the mansion, desperate to win some political favour. Among the worthy organisations competing for government largesse this year via the pre-Budget submission process are  Alzheimer’s, Arthritis, Kidney Health, and Vision 2020.       

All of these organisations are well put-together outfits with a well-rehearsed spiel about why they deserve the ultimate prize of a multi-million dollar 5 year funding commitment from Government. But, like the Bachelor, the Health Minister is under strict instructions that while she may flirt with as many causes as she likes during the year, on Budget Night she needs to pick the winners and send the rest home rejected.

Prediction: So who will get the rose this Budget night and who will be sent packing? The Government will be looking for a match that makes it look good on the political stage and will want to avoid rejecting a cause that is popular with the general public. It will be a tough decision for the Minister but Alzheimer’s Australia is looking good at this stage for the chance to develop a long term relationship with government, with Diabetes as a perennial hopeful a close second.

Risks: Rejecting a popular candidate can backfire if they have strong support from the viewing public. The Government will be banking on the Budget night media overload to distract people from the number of worthy but unsuccessful causes which will go home empty handed.

Big Brother

A number of wildly different personalities trapped in a confined space together and forced to collaborate on impossible challenges while secretly planning to stab each other in the back? It could be Big Brother or…..possibly…..a COAG meeting. For most of the year COAG drives the Federal Government crazy. But on Budget Night it can be a useful tactic to throw down an offer to the states and territories, tying it to unrealistic or unachievable conditions, knowing all along that the promised funding need never materialise. This gives the Government someone to blame when the issue is not addressed and distracts viewers from the fact that the Commonwealth has neither the means nor inclination to genuinely tackle the problem in the first place.

Prediction: the Government has already used this tactic in the lead-up to the Budget, announcing a dental program to provide 10 million Australian’s with access to public dental care which turned out to rely on the states and territories to provide the actual services, despite the fact that they have no capacity to meet the expected increase in demand.

Risks: there is always the possibility that the states and territories could put aside their individual agendas and use their collective strength to force the Commonwealth to offer genuine collaboration and funding partnerships on a specific issue. However, based on previous performance, this risk is very low.

Dancing with the Stars

Just as celebrities can make watching people learn to dance interesting, celebrity endorsement can also spice up an otherwise boring public policy announcement. But as in Dancing with the Stars, a poor choice of celebrity can make the whole show look clumsy and unbelievable and a minor mis-step can result in crippling accidents.

Prediction: There are a raft of Coalition-friendly celebrities on the boards or governing committees of health and medical groups who would make likely candidates. Alzheimer’s Australia would have to be the front runner, with Ita Buttrose as Ambassador and Peter Cosgrove, Patron. But watch out for Amanda Vanstone who could pop up in a number of places as she is both the Federation Chair of the Royal Flying Doctor Service and Chairwoman of Vision 20/20.

Risks: There’s always a chance that the celebrity could do such a good job at grabbing attention that they become the focus and no-one remembers the content of the policy or funding announcement, Or (more damagingly) the celebrity can turn maverick, using the platform to plug his/her own issues ignoring the cause that brought them there in the first place.

Survivor

In public policy, as in Survivor, sometimes the least likely candidates show an impressive ability to stick around, despite being eminently unsuited to their environment and plainly unable to meet the challenges thrown at them.
Private Health Insurance should have been voted off the health policy island in 1983, when Medicare arrived. But it has somehow stuck around, by keeping its head down in difficult times and aligning itself with key powerbrokers when opportunities arise.

Governments of both persuasions seem to have entered a long-term alliance with the private health insurance sector, naively trusting them to deliver on their unrealistic promises to improve quality and efficiency of care, not realising that the funds are acting out of self-interest and will quickly back out of any deal which does not deliver them individual gain.

Prediction: Recently, private health funds have been arguing for a greater role in health funding decisions, for example, by refusing to pay for certain services in private hospitals and arguing for price reductions for prostheses. This could be used by the Government to justify cost cutting which otherwise it wouldn’t have the political mettle to pursue.

Risks: by continuing to allow private health insurance to be part of our health funding tribe, we could end up in the situation where we are throwing billions of dollars a year in tax payer funded subsidies at an inefficient and inequitable funding system which meets the needs of only a minority of the population while ignoring the underlying structural barriers to improving equity and access to care for all Australians…oh……hang on…………….

The Biggest Loser

Despite what the politicians like to tell us, Budget Night always brings more losers than winners. So who will be the biggest loser this Budget? Unfortunately, there are a number of potential candidates for this role:

Indigenous health is unlikely to get anything near what NACCHO estimates is the funding required to reduce the gap between the health of Aboriginal and Torres Strait Islander Australians and the general population.

The ongoing separation of the health, ageing and disability portfolios increases fragmentation of services and creates barriers to developing genuinely integrated policies and programs, as argued by the Australian Healthcare and Hospitals Association in its Pre-Budget Submission. It also makes it more difficult to develop broad policies targeting disadvantage on a number of fronts, such as the policies supported by Consumers Health Forum in the early childhood years, along with other evidence-based strategies for reducing long-term health care costs.

A focus on specific diseases, risk factors and population groups conceals the importance of the broader social determinants that govern individual and population health and prevents the development of a genuinely consumer-centred health system.   

Prediction: All of the above.

Risks: If we keep ignoring these priority areas, we will end up with a health system that, despite its many benefits, still continues to spend more than it needs to on health services, and less than it should on keeping people healthy. We will also fail to address the structural and cultural barriers that currently prevent some groups of Australians from accessing the care and support the need to maximise their health and well-being.