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Beyond the back-slapping, and asking some tough questions about Medicare and the scale of reform that’s needed

Alison Barrett writes:

Structural health reform is urgently needed to address inequities in access to healthcare and health inequalities – which are set to escalate dramatically in the absence of political leadership, health leaders warned this week.

They called for a genuine political commitment to meaningful health reform, and raised concerns about policy measures and debates that focus too narrowly on issues such as bulk billing rates and indexation of rebates.

Experts also sounded a caution about the current “back-patting” celebrations of Medicare’s 40th anniversary, suggesting that Australia does not in fact provide universal, equitable access to healthcare, and has much to learn from other countries’ health systems.

A fundamental rethink of what Medicare is and how it works is required, participants in a #CroakeyLIVE webinar marking Medicare’s 40th anniversary were told this week.

The webinar, facilitated by Dr Megan Williams, a director and member of Croakey Health Media and principal of Yulang Indigenous Evaluation, was convened to help inform Croakey’s year-long project, #Medicare40Years, which will investigate health reform options, with a focus on solutions and innovation.

Professor Martin Hensher, the Henry Baldwin Professorial Research Fellow in Health Systems Sustainability at the Menzies Institute for Medical Research, suggested that Medicare may now be inadvertently driving commercialisation, financialisation and privatisation, and taking us further away from a universal healthcare system.

Dental care, mental healthcare, healthcare for people in prison and after release, and the care provided to First Nations, rural, remote and multicultural and culturally and linguistically diverse communities were among major gaps identified. Other issues of concern included inequitable access to allied healthcare, the impact of corporate medicine upon general practice and how best to pay for pathology and diagnostic imaging.

Equity concerns

Associate Professor Lilon Bandler, Principal Research Fellow at Leaders in Medical Education Network, said that rather than “the same old, same old – increased rebates, new item numbers”, the health reform focus should be on “some thoughtful creative approaches, informed by some consideration of successful models elsewhere, globally”.

“I’m really conscious of the fact that these conversations about different item numbers increasing really misses the point when it comes to serving populations who are already under-served by healthcare access,” Bandler told the webinar.

She also stressed the importance of developing models with salaried GPs, rather than fee-for-service, especially for better meeting the needs of marginalised and under-served populations.

Bandler said: “There are a large number of non-citizens with no access to Medicare, who are homeless and unemployed. Can we consider how Medicare should be serving them?”

Allan Groth, Director of Policy and Strategy at Services for Australian Rural and Remote Allied Health, said Australia was far from having a universal healthcare system, as “chunks of Queensland the size of Victoria” had no GP, surgery, pharmacy or ACCHO.

Echoing Hensher’s concerns about Medicare entrenching inequities, Groth asked: “Has the mechanism turned out to be the problem?”

Professor Ian Hickie, Co-Director, Health and Policy at The University of Sydney’s Brain and Mind Centre, also raised equity concerns, citing a colleague who said they were “sick of poor solutions for poor people”, and saying that Australia needed to move beyond providing universal access to low level care.

Hickie said it was important to distinguish between what people mean by Medicare, which is basically a health financing option for one part of the health system, as compared with what will the best healthcare systems look like in the future.

These would ensure affordable access to high quality “personalised, measurement-based, appropriate” healthcare.

He said it is quite challenging “to provide affordable access to high quality care across our whole system. Our federated system and governance systems are made more challenging. To face the reality, the inequity has grown.”

Hickie said Medicare discussions should reflect “more broadly” on the challenges we face and how the health system can adapt. (Also see Hickie’s comments in this previous article).

Political will?

Professor Virginia (Ginny) Barbour, Editor-in-Chief of The Medical Journal of Australia and Director of Open Access Australasia, highlighted the importance of political commitment to reform.

Jennifer Doggett, a health policy analyst and Croakey Health Media member, said high-level political support for meaningful health reform was lacking, and this was not helped by divisions within the sector.

“In the absence of some catastrophic event giving political licence for reform, it would need to be driven by a whole-of-sector agreement around what needs to change,” she said.

“Governments are very reluctant to progress reforms while there is major division among stakeholders.”

Also see this recent Croakey article, where Doggett said that “successful reform requires a ‘perfect storm’ of alignment between political interests, practical possibilities and community support”.

Echoing Doggett’s comments, Dr Ruth Armstrong, a member of Croakey Health Media, said: “Medicare at 40 is a bit of a bogged-down beast. With the ever-revolving political cycles, how do we go about reform?”

According to Hickie, an opportunity exists to have “a much more serious political dialogue” on these issues with the current Federal Labor Government, than has been the case the previous decade.

Several webinar attendees highlighted the importance of consumers and communities in driving discussions about healthcare reform, and in marshalling political support for meaningful change. It was also important to focus on place-based solutions and innovation.

“There is a lot of consumer education and consultation that needs to happen to generate public support for a reform agenda,” said Doggett.

“Most people don’t understand how the health system works and don’t have a good understanding of what the solutions are.

“Unless there is strong public support, the Government won’t take on the vested interests that would oppose reforms.”

Learn from other countries

Hickie told the webinar “if [we] believe in equity” moving forward, we should consider how we are going to make use of technology, workforces, infrastructure and changes in education, how we finance any changes or reform and the role of government in supporting changes.

Healthcare systems around the world are facing similar challenges in terms of increasing demands, limited workforce and limited resources, he said.

We can learn a lot from other countries, particularly developing countries, and how they deliver population healthcare, he said, noting that Australia has a tendency to pat ourselves on the back about what a great health system we have, when in reality it is “under real pressure”.

The #Medicare40 project will also look to lessons from the past. As Jennifer Doggett and Dr Lesley Russell wrote last year, calls for reform to Medicare have been going on almost as long as Medicare has been around.

More than 15 years ago, a previous Labor Government embarked on a comprehensive approach to health system reform via the National Health and Hospitals Reform Commission (NHHRC).

Despite a comprehensive consultation process and extensive involvement from the health sector, most of the NHHRC recommendations have not been implemented.Croakey thanks all participants in the discussion, including those who were off camera and are not pictured here. Above, from top L to R, are: Dr Lilon Bandler, Professor Martin Hensher, Professor Virginia Barbour, Dr Sally Fitzpatrick, Professor Ian Hickie, Charles Maskell-Knight, Dr Megan Williams, Naomi Sheridan, Jennifer Doggett, Clare Mullen, Dr Ruth Armstrong and Allan Groth.


A note from Croakey Health Media

We are seeking sponsorship for the #Medicare40Years series of webinars, and welcome approaches from organisations interested in supporting informed public debate about health reform. Contact us.


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