Calls in Australia and globally for governments to enact austerity policies to claw back their outlays on COVID-19 responses should cause deep concern, according to a recent letter to The Medical Journal of Australia, echoing similar concerns reported by Croakey last year.

The 2021-22 Budget will be critical for Australians, for what it does and doesn’t deliver.

Croakey editor Jennifer Doggett has pored over health-related Budget submissions to compile this comprehensive #LongRead below. Don’t miss her analysis of what should and shouldn’t be in the Budget, as well as her award for “most egregiously self-interested proposal”.

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Jennifer Doggett writes:

With momentum building for an early election, this year’s Federal Budget will be crucial for both the Government and the Opposition.

The Government will aim to use the Budget platform to sell its economic recovery plan and convince the electorate to give Prime Minister Scott Morrison a third term in office.

Meanwhile the Opposition will be looking for some much needed traction for its economic and policy agenda, which will be vital to give Labor a fighting chance at the polls.

Both parties are likely to spend or promise to spend up big, providing the health sector with the best opportunity for years to attract the level of funding needed to tackle major health challenges.

As always, peak health groups have provided a raft of funding and policy proposals in their pre-Budget submissions. Here is a sample of their key asks from this pre-election, pandemic-recovery Budget.

Pre-Budget submissions can be found on the Treasury website.  

Sure things (the issues the Government can’t afford to ignore)

 Aged care

Successive federal governments have ignored repeated calls from the health sector for additional funding and policy changes to improve the safety and quality of aged care.  The tragic results of this neglect were apparent last year when 685 residents of aged care facilities died of COVID-19.

The Aged Care Royal Commission (due to report on 26 February) will hand the government a blueprint for reform of this sector, leaving no more excuses to avoid the big spending measures necessary to ensure older Australians receive the level and quality of care they deserve.

Along with the recommendations from the Royal Commission, the Government can also look to submissions from stakeholder groups to put together its budget package.

One of the most consistent recommendations from these submissions is for increased nursing ratios in residential aged care facilities (RACFs).  This was a key request from the Australian Nursing and Midwifery Federation (ANMF),the Australian College of Nursing (ACN), the Australian Healthcare and Hospitals Association (AHHA) and the Australian Medical Association (AMA).

ACN also called for a targeted strategy to develop nursing leadership in mid-career nurse leaders and executive nurse leaders working in aged care.

Increased funding for home care packages was proposed by the AHHA, Catholic Health Australia (CHA), the Consumers Health Forum (CHF) and the Royal Australasian College of Physicians (RACP). The AHHA also called for funding for data development to measure and monitor unmet need and equity of access to aged care services.

Young people in RACFs are an important but often forgotten group and the AHHA recognised the need for funding for improved care and accommodation options for them.

The potential for nurse practitioners (NPs) to make an increased contribution to residential aged care  was highlighted in the ANMF’s submission. They recommend funding designated salaried NP positions in each Primary Health Network to support RACFs in providing quality care and to reduce ED presentations and hospital admissions.

More funding for doctors working in aged care was proposed by the AMA, CHF and the Royal Australian College of General Practitioners (RACGP). The AMA wants Medicare rebates for services in RACFs increased by “at least” 50 percent and the RACGP has called for an ‘extended’ Level B MBS consultation item that recognises the extra work involved for those GPs who spend more time with their patients.

The RACP called for funding to support high-quality palliative and end-of-life services in residential aged care settings.  They also want better training in dementia care to all service providers and funding for Primary Care Dementia Nurses positions in primary healthcare.

CHF highlighted the need for improved medication management for older people by funding dedicated pharmacists to provide medication reconciliation and management services in RACFs  and community-directed medication management packages for people living at home receiving Home Care Packages.

Mental health

In 2020 the Productivity Commission inquiry into Mental Health found that the economic impact of mental illness in Australia was over $700 million per annum in direct costs and lost economic productivity.

With the ongoing impact of COVID-19 pandemic adding to pressures on mental health, this figure is likely to be even greater in 2021-22.

The economic case for improving the nation’s mental health is clear. But the challenge in this budget will be to target funding to those most in need and to address the inequities in many existing mental health programs.

Focusing funding on the primary care sector is one key strategy proposed by the ANMF and a number of mental health stakeholder groups. This includes additional funding for community-based nursing services, with a specific focus on addressing the gap accessing after hours mental health care. The ANMF also suggests more community-based mental health in-reach nursing services to meet the needs of residents within supported residential services.

Mental Health Australia (MHA) called for Primary Healthcare Networks (PHNs) to lead local service design with strategies to ensure that the voice of vulnerable groups such as the LGBTQI+ community are included, as well as expanded access to National Translation and Interpreting Services to provide translators to support new and emerging CALD communities.

The CHF wants the government to implement the recommendations from the Mental Health Reference Group of the MBS Review including developing a creating a triaged structure for the Better Access items and extending access to Mental Health Treatment plans to people at risk of developing a mental disorder.

Things everyone agrees should be a priority

Indigenous health, rural and remote health and prevention are health issues that consistently rate as high priorities for the health sector but never seem to attract the level of funding they deserve from governments.

If Prime Minister Scott Morrison and Treasurer Josh Frydenberg decide that this is the year to reverse this trend, they will have a raft of evidence-based recommendations to choose from in the pre-Budget submissions.

Indigenous Health

NACCHO’s comprehensive submission includes seven cost-neutral policy proposals focused on  practical initiatives that would deliver greater service capability and improve outcomes for Aboriginal and Torres Strait Islander people. These have been informed by NACCHO’s consultations with its ACCHO members, the eight NACCHO affiliates in each state and territory and other partners in the sector.

These proposals include:

• improving Aboriginal and Torres Strait Islander housing and community infrastructure from existing funds in Indigenous Advancement Strategy (IAS)
• returning funding for social and emotional wellbeing services for Aboriginal and Torres Strait Islander peoples from the Indigenous Advancement Strategy (IAS) to the health portfolio
• investing in a range of initiatives to improve Aboriginal and Torres Strait Islander oral health
• developing a national workforce development strategy to boost the employment of Aboriginal and Torres Strait Islander allied health professionals and other health workers
• reducing the over-representation of Aboriginal and Torres Strait Islander children and young people in out-of-home care and detention through better use of program funds.

In addition to these proposals, the ANMF called for funding and support for the development, implementation, and evaluation of Birthing on Country programs in urban, regional, and remote locations as well as the inclusion of cultural safety training  into the annual registration and continuing professional development requirements of all healthcare professionals.

The National Health Leadership Forum (NHLF), a collective partnership of 12 national organisations who represent a united voice on Aboriginal and Torres Strait Islander health and wellbeing, also provided a detailed submission focused on the cultural determinants of health, self-determination and practical, culturally informed, rights-based approaches to closing the gap between Aboriginal and Torres Strait Islander and non-Indigenous Australians.

Among their specific recommendations are increased funding for Aboriginal Community Controlled Organisations, more investment in targeted, needs-based comprehensive primary health care and endorsement and implementation of the National Aboriginal and Torres Strait Islander Health Workforce Plan.

Other recommendations in this area included a proposal from the RACP to establish models of medical service provision and sustainable funding which ensure equitable and appropriate access for Aboriginal and Torres Strait Islander older people to consultant physician, palliative medicine and geriatric medicine services, across varying locations.

They also want to reduce the barriers that Aboriginal and Torres Strait Islander older people experience in relation to health services (including through investing in improving the cultural competency of healthcare professionals).

The AMA called for an overall substantial increase in funding for Indigenous health, based on the much higher health needs of Indigenous communities and recognising that chronic disease is inextricably connected to the social determinants of health.

The AMA also identified oral health, chronic otitis media and rheumatic heart disease as key health issues for Indigenous communities and called for funding for services that divert Aboriginal and Torres Strait Islander people from prison.

Rural health

The National Rural Health Alliance has two proposals targeting rural, regional and remote Australian communities.

The first to create six place-based health and wellbeing networks to address under-servicing of health, aged care and disability services in rural and remote communities. These networks would address the inequity of access to health care for people in rural Australia and would provide economic stimulus for regional communities across the country.

The second proposal is a comprehensive package aimed at integrating national digital health strategies and increasing the uptake of digital health initiatives, digital health literacy and connectivity. This would increase digital inclusion, awareness and participation in digital health solutions for health consumers and health practitioners and provide an overarching blueprint for rural digital health, to complement and consolidate existing national digital health strategies, including COAG’s National Digital Health Strategy and the Australian Digital Health Agency’s National Digital Health Workforce and Education Roadmap.

The Menzies School for Health Research called for a four-year extension to the HOT North project which supports researchers and practitioners working to improve the health of all people living in northern Australia, with a strong focus on closing the gap in Indigenous health.

More than two-thirds of HOT North activities to date have focused on addressing the main diseases causing Indigenous health disadvantage, such as youth and maternal diabetes, rheumatic heart disease, respiratory infections and skin diseases.

Activities funded under this program have increased access to Aboriginal language interpreters at Royal Darwin Hospital, which resulted in a significant decrease in early self-discharge rates for Aboriginal inpatients.

They have also supported the development of mosquito-borne virus surveillance methods to monitor for incursions of Murray Valley and Japanese encephalitis viruses and established the 147-member Women in Tropical Health (WITH) Network, which includes support for 13 Aboriginal and Torres Strait Islanders working in health research.

Prevention

A number of submissions pointed out that currently Australia spends only 1.4 percent of the health budget on prevention, one of the lowest among OECD countries.  An increase in spending in this area to 5% of the annual national health budget was proposed by the OPC, the ANMF and the Public Health Association of Australia (PHAA).

PHAA’s submission also identified the need for an organised system for assessing, approving and funding disease prevention programs, similar to that in place for the MBS and PBS.

The AHHA called for an increase in preventive health funding, focused on addressing risk factors and determinants including overweight and obesity, alcohol misuse and abuse, tobacco consumption, inequality and immunisation.

AHHA also wants increased support for Primary Health Networks and Local Hospital Networks to develop shared regional needs assessments, priority setting and funding for regionally targeted preventive health initiatives that respond to local community needs.

The ANMF proposed the re-establishment of a national dedicated preventive health body and increased incentives to encourage changes in both health provider behaviour and individual behaviour, which will lead to better health outcomes.

It also suggests establishing preventive primary care systems that encourage people to enrol in wellness maintenance programs, with assistance from a range of health professionals such as general practitioners and nurse practitioners.

A strategy to prevent Type 2 Diabetes Mellitus was proposed by the RACP, including targeted primary and secondary prevention to retain young people and their carers in populations at risk in ongoing follow-up.

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The things we’re not talking about (but should be)

Budgets are as much about public relations exercise as they are about policy. This means that worthwhile policies can often get bumped off the Budget agenda in favour of more PR-friendly options.

Two important issues that we probably won’t see discussed on Budget night, but which should be a high priority for funding, are palliative care, birth trauma, injury prevention and GP research.

Palliative care

Investment in palliative care means people can live well until their death, with optimal management of symptoms, support and care in the place of their choice.

Investment in palliative care also makes economic sense. Research consistently shows that people living with a life-limiting illness who receive palliative care, compared with those who do not, have fewer hospitalisations, shorter hospital stays, reduced use of Intensive Care Units and fewer visits to Emergency Departments (EDs).

In its Budget submission Palliative Care Australia (PAC) called on the Australian Government to develop a National Health Agreement on Palliative Care between the federal and State and Territory governments, supported by the establishment of a National Palliative Care Commissioner.

Palliative care in residential aged care  is also a key focus for PCA: 35 per cent of all deaths in Australia occur in RACFs, yet palliative care in this sector is significantly under-funded and has not been included as an Aged Care Quality Standard.

As well as urging  increased funding for palliative care in RACFs, PAC also propose a Palliative Care Supplement for recipients of Home Care Packages (HCPs) who have a life-limiting illness.

RACP also called for additional specialist palliative care doctors and nurses across Australia, with a focus on non-cancer services in hospitals and in other settings such as RACFs, people’s homes, in rural and remote communities (including via telehealth) and among other underserviced populations.

Birth trauma

Around one in three women who have given birth experience birth trauma but most don’t receive the help they need for this disabling condition with often lifelong consequences.

The Australian Physiotherapy Association has proposed a range of measures to identify and treat birth trauma, including Medicare-subsidised access to physiotherapy assessment and management via GP referral for all Australian women during pregnancy and up to one year postpartum.

They also suggest providing women with in-hospital access to imaging services that diagnose physical birth trauma as early diagnosis will help reduce future surgery for conditions such as prolapse and incontinence.

Injury strategy

In recent years infectious and non-communicable diseases have been in the policy spotlight, leaving other health threats, such as injury, off the political and policy agenda.

This could be a mistake. In Australia injury is the leading cause of death of all people aged between 1 and 44 years, costing almost $9 billion in recurrent health expenditure each year (2015-16 figures).   As with many health conditions, injuries impact more on people experiencing socio-economic disadvantage, people living in rural and remote areas and Aboriginal and Torres Strait Islander people

The George Institute, which recently developed the National Injury Prevention Strategy for the government, has proposed an implementation plan for this initiative, including tracking and reporting of progress against key outcome measures. It also wants funding for the evaluation of community-based injury prevention programs, a centralised knowledge bank of effective injury prevention and more research on injury prevention.

GP research

Almost 90 percent of Australians visit their GP each year – more than any other health professional. This should make research into general practice and primary health care a high priority for governments, given that improvements in general practice can deliver benefits to almost every person in Australia.

It’s therefore surprising that currently less than one percent of funding in the Medical Research Future Fund’s 10-year investment plan is dedicated to primary care research.

Changing this is a priority for the RACGP, which has suggested increasing the primary care portion of the Medical Research Future Fund from one percent to eight percent and providing targeted support for GP-led research, including specific funding for Aboriginal and Torres Strait Islander and rural researchers.

RACGP suggests that this research should focus on better integration of care between general practices and local hospitals and ways in which better coordination of services, provided by general practices, can support health and wellbeing and improve health outcomes.

SF blood pressure monitors

High blood pressure (BP) is the key risk factor for stroke and heart disease and home self-monitoring of BP is one common strategy to manage this condition.

However, an evaluation by the Stroke Foundation of almost 1,000 machines available on the Australian market found that only five percent of machines were validated. This means that many of the 4.1 million Australians with uncontrolled high BP are relying on machines that provide inaccurate and misleading results.

A home blood pressure monitors “best buy” program is proposed by the SF would address this issue with potentially significant and long term results.

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Things that always seem to be in the “too hard basket”

When major health threats barely rate a mention in a federal budget it’s usually because they require a policy that is too expensive, too complex or too politically risky for the government of the day to take on.

All three of these reasons can explain why dental health and obesity are not the major focus of federal budgets, despite their central importance to the current and future health of our community.

Oral and Dental Health

Dental decay is the most costly diet-related disease in Australia and can have serious negative effects on general health and on quality of life. It also increases the risk of other serious health conditions such as heart disease and diabetes. Many Australians do not have adequate access to dental care, due to cost, geography and cultural barriers.

Dental services should be a high priority for governments. But despite the clear health and economic benefits of increasing access to dental care, this area of health policy remains neglected at both the federal and state levels.

Health groups continue to lobby strongly for more public health funding and this year’s budget submissions are no exception.

A universal dental health scheme is the end goal for CHF which has suggested an Adult Dental Benefit Scheme for adults on low incomes as a first step.

The AHHA also makes a number of recommendations to support dental health, including a National Partnership Agreement on Public Dental Services for Adults, funding for water fluoridation infrastructure, dental teaching clinics in Aboriginal Medical Services, and the creation of an Australian Chief Dental Officer position to provide national coordination of oral health.

Obesity

Australia’s high rates of obesity are a major cause of preventable morbidity and mortality and according to a recent OECD report (the 2019 Heavy Burden of Obesity: The Economics of Prevention report by the OECD), cost around 3.1% of our GDP.

The complexity of addressing this issue has, along with lobbying by powerful interest groups, such as the Food and Grocery Council, mean that governments have tried to avoid taking action.

To address this issue, the Obesity Policy Coalition called for funding for an implementation plan for actions related to the National Obesity Strategy and the National Preventive Health Strategy.

It also wants a Productivity Commission inquiry into obesity and its impact on the economy,  funding to continue uptake of the Health Star Rating system and a National Food and Nutrition Strategy.

The RACP wants a national COAG-led strategy on obesity, including dedicated funding for states and territories to provide equitable access to bariatric surgery for public hospital patients.

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Things that should be done (but won’t because powerful vested interest groups are lobbying against them)

Vested interest groups have a disproportionate impact on health policies in Australia and use their profile and deep pockets to influence government policy and funding decisions.

Unfortunately, many of the best suggestions in the pre-Budget submissions are unlikely to be picked up due to lobbying from vested interest groups.  These include a sugar tax, private health insurance reforms and extended prescriptions.

Sugar tax

A sugar tax on soft drinks would deliver both increased health outcomes and increased taxation revenue – a win-win’ for governments.  In fact, a recent Australian study found that a 20 percent health levy on sugary drinks could result in a 12.6 percent decline in consumption of sugary drinks and an overall decline in obesity of 2.7 percent in men and 1.2 percent in women. This study estimated that 1,606 more Australians would be alive in 25 years if the levy were introduced.

The OPC estimates that a health levy on sugary drinks would provide a significant revenue source for the Government, by delivering between $400 and $642 million annually as well as reducing healthcare spending.  A sugar tax is strongly supported across the health sector, including by the PHAA  the RACP, CHF, NACCHO and AHHA.

However, despite this high level of support, the Government is unlikely to support a sugar tax this budget due to strong opposition from the Australian Beverages Council, the peak body for soft drink manufacturers.

Direct referral by physiotherapists and nurse practitioners

A wide body of research demonstrates the value of multidisciplinary and coordinated primary healthcare.

However, Australia’s Medicare funding system does not always support this type of care, partly because in the primary healthcare sector the MBS almost exclusively funds GP services.

Broadening MBS funding to include nursing and allied health services could increase consumers’ access to these types of care and reduce unnecessary GP visits for referrals, making the system more efficient overall.

This was a focus of the submission from the Australian Physiotherapy Association (APA), which suggests that physiotherapists could refer patients directly to medical specialists and diagnostic imaging, within individual scope of practice, under a clinical governance framework that recognises the role of physiotherapists as health system custodians in their area of expertise.

The ANMF wants increased MBS rebates for NPs and midwives as well as MBS item numbers for NP after-hours services and procedural services (similar to GPs). They also call for funding for the expansion of NP roles, nurse-led and midwife-led clinics in health, aged care, maternity care, mental health, and primary care, designated salaried positions for NPs in small rural and remote communities and infrastructure funding for NPs and midwives to establish independent practices.

While all these measures would be popular with consumers, they will face opposition from the medical profession, which does not want to give up its near monopoly over Medicare funding.

Mandatory private health insurance payouts

The government provides around $6 billion to private health insurance every year in direct subsidies (and several billion more indirectly).

Despite the fact that health funds receive such large sums of taxpayer money, health funds are under no obligation to return any profits they make to the Australian community.

ANMF suggests introducing a mandatory minimum payout of 90 percent of revenue, which it estimates would lower premiums across the board by two percent, as well as encouraging funds to be more efficient.

This would be a popular policy with consumers but the powerful PHI lobby will no doubt ensure it doesn’t appear in this or future budgets.

Extended prescriptions

In 2018 the Pharmaceutical Benefits Advisory Committee recommended that doctors should be allowed to prescribe larger quantities of certain medicines for patients with chronic stable conditions.

This proposal was supported by the AMA, the RACGP and CHF; however, the Government backed away from this change after it was opposed by the powerful Pharmacy Guild.

CHF has called for this measure to be included in the upcoming budget, along with other changes to administration of the PBS, including automating eligibility for the Pharmaceutical Benefits Schedule safety net and allowing consumers with predictable high usage of PBS medicines to spread their co-payments evenly over a year.

So far Health Minister Greg Hunt has ignored most of the advice from inquiries and reviews on pharmacy reform. This means that, despite the clear benefits of extended prescriptions, they are unlikely to be included in the upcoming budget.

PHI – vertical integration, incentives

An increasing trend among PHI funds is to ‘vertically integrate’ their businesses through acquiring companies that provide healthcare services, for example those providing ‘hospital substitute’ care.

This enables health funds to incentivise doctors to make particular referrals or treatment recommendations, either through the design of remuneration arrangements or through by limiting cover of treatment options. For example, some doctors are offered increased payments by health insurers to admit a patient to a day hospital rather than an acute hospital.

This has raised stakeholder concerns about the potential risks to consumers of a conflict of interest when health funds become both the provider and funder of their care.

To reduce this risk, the Australian Private Hospitals Association (APHA) and CHA suggest increasing transparency about these arrangements through requiring that consumers be made aware of such incentives and limitations. They believe this will minimise the opportunity for health insurers to force a patient into a care pathway that is in the financial interest of the fund, rather than the clinical interests of the patient.

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Things that should be part of the health portfolio (but aren’t)

Climate change

Climate change is the single largest threat to global health with the potential to undermine the past 50 years of public health gains. Yet action on climate is not generally included in the health budgets of Australian governments.

The Climate and Health Alliance, representing 45 member organisations, wants this to change. It proposes a comprehensive series of measures, as outlined in its National Strategy on Climate and Health, to support the development of a healthy, regenerative, and just society and economy.

These measures focus on the following areas:

1. Supporting healthy and resilient communities
2. A sustainable and climate-resilient health care sector
3. Health-promoting and emission-reducing initiatives, in particular in relation to energy efficiency, housing and transport
4. Emergency and disaster-preparedness
5. Education and capacity building
6. Leadership and governance
7. Research and data
8. Thriving ecosystems.

Several health groups, including CHF and the ANMF, also supported the development of a National Strategy on Climate, Health and Wellbeing, based on CAHA’s strategy.

Specific issues identified by the ANMF and RACP regarding climate change include increased government funding for climate-resilient health systems and climate change mitigation research, as well as a staged transition to zero emissions energy sources.

They also suggest that programs and initiatives should support those most adversely impacted by climate change, including people living in drought and disaster affected regions in Australia and neighbouring regions in the South Pacific.

Newstart – income inequality

The fair and equitable distribution of wealth throughout the Australian community is important to ensuring consistent access to all healthcare systems by all individuals.

As the ANMF’s submission states: “An economy that maintains such a distribution of wealth holds considerable potential to realise opportunities in the overall reduction of costs to health systems through enabled access to services, early intervention and proactive engagement.”

Along with CHF and the MHA, the ANMF called for increases in Newstart, Youth Allowance and related payments and mechanisms to ensure income support payments continue to increase in line with the cost of living.

The ANMF also proposed a reform of tax concessions, such as for superannuation, which bring most benefit to those with high incomes.

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The most egregiously self-interested proposal

The health sector has its fair share of vested interested groups  that can stymie sensible policy reforms (see above) and attempt to influence government for their own advantage.

This Budget cycle, the award for the most egregiously self-interested proposal goes to Private Healthcare Australia (PHA), the peak body for the private health insurance sector.

Their submission, along with those from the APHA and CHA, notes the declining levels of support for PHI among the Australian population.

The APHA’s submission attributes this in part to the government’s own “policies designed to incentivise uptake of private health insurance”,  which it says “In some instances…now act to block that choice.”

CHA’s submission argues that the drop in PHI membership in 2020 reflects the restrictions on the availability of elective surgery and allied health due to COVID-19.

PHA’s submission also describes how almost 200,000 high income Australians do not have PHI even though it would cost them less than they pay in extra tax via the Medicare Levy Surcharge.

Despite this clear evidence that many Australians do not want PHI, even with very generous government subsidies, PHA wants more money spent on supporting their members.

In particular it suggests increasing the rebate to 40 percent of premiums for 18-39 year olds (at a cost of approximately $1.1bn in 2024-25) as well as providing a Fringe Benefits Tax exemption for participating employees under the age of 40 (costing the Commonwealth  $584m in forgone taxes annually).

There are a number of useful suggestions from other stakeholders to address the identified problems with current PHI policies. Both the ANMF and CHF support a Productivity Commission inquiry into government support for private healthcare and the ANMF also called for a reduction in ancillary rebates, starting with removal of rebates for treatments with a poor evidence base.

As discussed above, mandatory minimum payout levels and increased transparency around vertical integration would also help address consumer concerns about the value of PHI.

The PHA’s apparent disregard for these suggestions from the health sector, in favour of additional government subsidies for their members, makes them a clear winner in the ‘egregiously self-interested’ category for the 2021/22 Budget.