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HealthWrap: Gun control, healthcare, tackling homelessness, cancer disparities and back pain

In the latest edition of The Health Wrap, Associate Professor Lesley Russell looks at an instructive international comparison of healthcare spending, some worrying – and encouraging – developments in gun control, the latest evidence on tackling homelessness, cancer inequities, and an important news series of articles on back pain.

Beneath her column are some links to other recommended reading and resources from the Croakey team, and some “tweets of note”.


Healthcare spending in high income countries: how does Australia compare?

A recent paper in JAMA looks at why healthcare spending is so much higher in the US than in 10 other high-income countries (including Australia).

It found that social spending and healthcare utilisation in the US do not differ substantially from other high-income nations; rather, the prices of labour and goods, including pharmaceuticals and medical devices, and administrative costs appeared to be the main drivers of the differences in spending.

The tables in this report are particularly well done and will prove useful to those looking for this information in a concise and comprehensible format. It is valuable to look at this report alongside the 2017 Mirror, Mirror report from the Commonwealth Fund. I summarised that report in an article for Croakey you can read here.

The JAMA paper echoes the findings of the Commonwealth Fund report and provides further details, with some important lessons for Australia. It is accompanied by several editorials. Here is my summary of the key points.

Healthcare expenditure

In 2016, total healthcare expenditure in the US was 17.8 percent of GDP, almost twice that of Australia (9.6 percent of GDP) and considerably more than the mean of the 11 countries (11.5 percent). This equates to $1,443 per capita in the US, $560 in Australia, $794 mean (all figures in this analysis are US$).

However if just public expenditure is considered, the US is not such an outlier, spending just 8.3 percent of GDP (Australia at 6.3 percent has the lowest public expenditure and the mean is 8.4 percent). It is important to note that, unlike the other countries considered which have national healthcare systems that cover almost everyone, the US public spending covers only 37 percent of the population.

The high levels of US healthcare expenditure are accompanied by high administrative costs (8 percent in the US compared to 1-3 percent in other countries; 3 percent in Australia).

Where does the money go?

The US spent only 19 percent of total healthcare expenditure on hospital care (this does not include day hospitals) compared to Australia’s 31 percent (mean 26 percent). There does not appear to be a significant correlation between funding spent on hospital care and funding spent on outpatient care.

The US has the highest expenditure for outpatient care (44 percent vs Australia 39 percent, mean 31 percent) but this is due to the high costs of doctors’ fees, pharmaceuticals and testing rather than an investment in primary care.

The data highlights where both the US and Australia could do more to improve health outcomes and reduce healthcare expenditure. Both countries have high rates of avoidable hospitalisations for diabetes (US 191/100,000 population; Australia 141; mean 125.6) and asthma (US 89.7/100,000 population; Australia 64.8; mean 42.4).

Australia spends even less than the US on prevention (Australia 2 percent; US 3 percent).

The value of Australia’s Pharmaceutical Benefits Scheme is highlighted by the per capita expenditure on medicines: in the US in 2016 this was $1,026, in Australia it was $346, the mean was $541.

Healthcare resources and workforce

The JAMA paper provides some data on resources like hospital beds, MRIs and CTs, doctors and nurses on a population basis. The only significant correlation with healthcare costs is salaries for nurses, generalist doctors and specialists. Not surprisingly, US remunerations are high, but Australian specialist doctors’ incomes are also high (US $316,000; Australia $202,291; mean $182,657. These figures US$ are adjusted for purchasing power parity.)

Social issues

Across the 11 countries, the US had the lowest percentage of the population older than 65 years and the highest rate of poverty, with almost a quarter of the population living below the poverty line.

Total public social spending (on issues like the elderly, disabled, unemployed, families, education and housing) was 11.3 percent of GDP in the US and 13 percent in Australia (mean 15.3 percent).

Although the authors did not draw this point out, it’s interesting to speculate how austerity in social welfare programs translates into increased healthcare costs and poorer health outcomes.

Equity

Not surprisingly, and shamefully, Australia is an outlier here with 18.8 percent of total healthcare expenditure as patients’ out-of-pocket costs, well ahead of the US (11 percent) and the mean (13.3 percent).

One of the consequences of high OOP costs is that consultations are skipped: 22.3 percent of Americans and 16.2 percent of Australians reported that they had not visited a doctor because of cost (mean 9.4 percent).

Switzerland is an interesting exception here, with patients’ OOP costs comprising 25 percent of healthcare expenditure, although this does not seem to have a major impact on ability to access care.

• Also read this Canadian-focused analysis by Andre Picard, which begins with a French proverb that may also have wider resonance for healthcare comparisons: “When we look at ourselves, we despair; when we compare ourselves to others, we take comfort.”


Gun control – is Australia trying to emulate the US?

I’m currently in the US, watching the gun control debate playing out after the massacre at Marjory Stonemam Douglas High School in Parkland, Florida.

I’m in awe of the courage and wisdom of the teenage survivors who are really running a superb campaign and keeping this topic on the national agenda but saddened and disheartened at the lack of any meaningful political response.

President Trump and others have tweeted their “thoughts and prayers” and talked a lot, but clearly are intimidated by the NRA and the anti-gun control lobby. You can read my recent piece on these issues for Inside Story here.

Throughout the US debates and internationally, Australia’s gun laws – and their impact on public safety – are held out as exemplars. So it’s disappointing and upsetting to see Australian politicians looking to water these down.

Tasmanian Government looking to water down current gun laws

During the recent Tasmanian election, it was revealed at the last minute that the Liberal Party (which remains in government) has promised changes to the state’s gun laws that were enacted as part of a national agreement after the Port Arthur tragedy. The package of changes was not publicly released by the government prior to the election although details were provided to gun groups.

The package includes:

  • Extension of gun licenses for categories A and B firearms from 5 to 10 years.
  • Extension of licences for category C weapons (includes self-loading rifles and pump action shotguns) from 1 to 2 years and allowing these licence holders to have silencers.
  • Relaxation of the penalties for “minor” gun storage breaches.

The net effect is to allow greater access to category C firearms on grounds that this will help “agricultural producers, particularly farmers, to protect crops”. Farmers say they need these weapons to kill wallabies and possums.

Premier Will Hodgman has denied that this is a sneaky approach to a watering down of current laws. Many people will not agree with him.

Home Affairs Minister wants to create a gun lobby council

There was a chilling report last week that Home Affairs Minister, Peter Dutton, is considering establishing a firearm advisory council to “give the gun lobby a seat at the table” and allow gun importers to review proposed changes to firearm laws for “appropriateness and intent”.

This does not seem to have engendered any response from government, although both Shadow Attorney General, Mark Dreyfus, and former leader of the National Party, Tim Fischer, have spoken out against it. Fischer, who was Deputy Prime Minister when John Howard introduced the gun control laws in 1996, warns that an “NRA inspired” gun lobby is putting renewed pressure on Australian gun laws.

The Shooting Industry Foundation of Australia (SIFA) is very politically active; it gave political donations of $760,000 in 2016-17 to Liberals, Nationals and minor right wing parties in Queensland.

Tackling the causes of gun violence

While President Trump, the NRA and anti-gun control groups have gone to incredible lengths to avoid addressing the major problem in the US – ready access to assault-style weapons and ammunition – it is postulated that this senseless violence reflects what social scientists call “masculinity threat”. Obviously this is a highly debateable topic, but it is discussed well in this article.

A 2014 report from the Center for American Progress highlights how gun violence is devastating the American Millenial generation. Things have only deteriorated since that report was written.

March for our Lives

This Saturday, all around the US, millions of people will turn out for hundreds of March for our Lives events. I’ll be attending the one in Vail.

I agree with Tom Friedman who has cautioned against “faux activism”, but it is important to send a message to a do-nothing President and Congress. Ultimately, lasting resolutions to these issues – in the US and Australia – will come at the ballot box.


Tackling homelessness

On 14 March the ABS released its latest data on homelessness in Australia. The analysis compares data from the 2016 census with that from 2011 and 2006. On census night 2016 there were 116,427 people classified as being homeless, up 14 percent from 102,439 in 2011. Most of this increase was due to more older people and recent immigrants being homeless.

The good news is that the numbers of homeless Indigenous people, children and youths have declined.

While 60 percent of homeless people are aged under 35 years, the number of homeless persons aged 55 years and above has steadily increased over the past three census, with a 28 percent increase between 2011 and 2016. These older Australians (many of whom are women) have much less chance of escaping homelessness into formal housing. We need to understand more about the gaps in service provision that are responsible for this continuing growth in homelessness in this population group.

Immigrants from overseas now make up 46 percent of the homeless (although they comprise only 28 percent of the population). Many of these people live in shared and severely overcrowded accommodation.

There are significant numbers of people who are not classified as being homeless but are living in marginal housing and are at risk of homelessness.

Government policies on homelessness and housing

In 2008, the Rudd Government commissioned a white paper titled “The Road Home: A National Approach to Reducing Homelessness”. Rudd described homelessness as a “national obscenity” and set two goals for 2020: to halve homeless ness and to offer supported accommodation to all people sleeping rough.

Through the National Partnership Agreement on Homelessness and its replacement, the National Affordable Housing Agreement, the total expenditure on homelessness services has increased by 28.8% from 2012-13 to 2016-17.

But there has been no impact on the rate of homelessness and the Rudd 2020 goals will not be met. A recent article in The Conversation argues that numbers of homeless Australians will continue to rise unless governments change course on housing.

Links between poor housing and health

Poor housing is a key social divide, even in rich, first-world countries like Australia. Failure to see the importance of the social determinants of health like housing means a poor return on healthcare expenditure, and guarantees that health disparities will never be eliminated.

Homelessness and poor housing cause or contribute to many preventable injuries, infections and chronic diseases in a variety of ways. Individuals experiencing homelessness have higher rates of acute and chronic illness and many of these people have incredibly high rates of use of expensive healthcare service such as Emergency Departments and hospitals. Even if they get needed healthcare, without housing, their recovery and healing is compromised and delayed.

It is shocking that in a prosperous country like Australia that some one million people live in substandard housing and one in every 200 people are homeless.

Obviously action is needed, but politicians seem more focused on first world problems like the housing bubble and the pros and cons of negative gearing rather than the third world problems that face many Australians who are living in unsafe housing or who are homeless.

Indigenous housing

Perhaps as many as one-third of Indigenous households live in dwellings with major structural problems (e.g. rising damp, major cracks in floors or walls, major electrical/ plumbing problems and roof defects) and in remote communities many Indigenous people live in temporary or improvised dwellings.

The National Partnership Agreement on Remote Housing is set to lapse from July 1, and currently the Indigenous housing sector is facing uncertainty about its renewal and needed resources going forward. Presumably the Turnbull Government thinks an announcement in the May budget is timely enough.

A recent article for Croakey by Amy Coopes outlined the problems in the Northern Territory that were highlighted at the NT Housing Forum in early March. The Forum heard how returning control of Aboriginal and Torres Strait housing to community hands is essential for meaningful progress on health, education, employment and community sustainability.

The general lack of government attention to improvements in Indigenous housing in line with the needs and wishes of Indigenous communities is disturbing. It undermines efforts to tackle diseases linked to poor housing such as trachoma, rheumatic fever, otitis media and scabies, to address domestic violence and to provide dignity and family cohesiveness.

Comparisons between Indigenous and non-Indigenous children in the Longitudinal Study of Australian Children show improvements in housing translate into gains for Indigenous children’s health, social, and learning outcomes.

The Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report was critical of a focus solely on remote housing. Sub-standard housing is also a problem in non-remote areas; for example, a quarter of Indigenous households in major cities were found to have major structural problems in 2014–15.

Looking to Finland for solutions to homelessness

The most successful approaches to tackling housing and homelessness, as exemplified by initiatives in the US and Europe, see this as a public health issue and take action accordingly.

Finland is the only European Union country not currently in the midst of a housing and homelessness crisis and the country has all but eradicated rough sleeping.

This is directly attributed to the implementation, beginning in 2008, of a policy called Housing First. The aim is to end homelessness rather than simply managing it (or even sweeping it out of sight). People are given permanent housing as soon as they become homeless and individually tailored support. This is a sound economic and social investment because stable living conditions enable the use of mainstream services instead of expensive emergency services.

Ironically Housing First was the approach proposed under the Rudd Government, but this promising strategy was dissipated by successive governments for lack of funding and political will. This illuminating article at Power to Persuade suggests that Housing First is especially useful for homeless people with co-occurring mental health and/or substance misuse issues because:

the approach adopted recognises the impact of adversity on a user’s often ambivalent or dismissive relationship with care. By allowing for longevity, flexibility, stickability and normality, Housing First avoids excluding people with difficult histories for behaving in ways that are not only entirely understandable, but also (to an extent) predictable.”

Croakey has an extensive archive on homelessness, with articles back to 2012.


Cancer disparities – poverty is a carcinogen

On March 15, the Australian Institute of Health and Welfare released the latest available information on national population screening programs, cancer incidence, survival, prevalence and mortality for Aboriginal and Torres Strait Islander Australians, compared with non-Indigenous Australians.

While Indigenous Australians are only slightly more likely (1.1 times) to be diagnosed with cancer than non-Indigenous Australians, they have a 50 percent lower five-year survival and are 1.4 times as likely to die from cancer. Lung cancer is the most common, followed by breast cancer in women, colorectal cancer and prostate cancer in men.

The report postulates that these differences are due to a higher prevalence of risk factors like smoking, poorer access to healthcare services, and lower uptake of screening programs.

The incidence rate for all cancers is highest in metropolitan areas, although there are variations in incidence by rurality for individual cancers (for example, cervical cancer rates are highest in outer regional and remote areas).

The growing Black-White cancer divide in the US

On the same day this analysis was released, there was an article “Black Cancer Matters” in the New York Times. It looked at the increased cancer risk for African Americans that accrues due to the economic consequences of racial discrimination.

Increasingly there is evidence that poverty is a carcinogen. In the US, socio-economic disparities affect where people live and the likelihood that poorer people live in contaminated environments, with poorer diets and higher levels of obesity – all risk factors for cancer. Poverty also governs timely access to diagnosis and treatment.

The poverty and social deprivation of Indigenous Australians is surely a contributing factor to their cancer survival rates, indicating that attention to the social determinants of health is as critical here as access to screening, early diagnosis and treatment.


Appropriate treatment for lower back pain

There are few issues in healthcare more painful and contentious than how to treat lower back pain. It’s a growing global challenge. The Lancet has just published a series on lower back pain.

The first paper discusses the complexity of the condition and the psychological, social, and biophysical factors that contribute to it. The second paper outlines recommendations for treatment and the scarcity of research into prevention of low back pain.

The last paper is a call for action by Australian, Professor Rachelle Buchbinder and her colleagues. They say that persistence of disability associated with low back pain needs to be recognised and that it cannot be separated from social and economic factors and personal and cultural beliefs about back pain.

The Australian media have reported these publications in the context of how much is spent (and wasted) by Medicare on inappropriate treatments like spinal fusion and opioid medicines; it is estimated that this amounts to $4.8 billion annually.

Meanwhile, cheap treatments like exercise and yoga that do work are rarely prescribed. “The elephant in the room is vested interests – among industry but also clinicians,” said Professor Buchbinder.

Clearly there’s more work here for the MBS Review which has previously released a report on imaging for lower back pain.

Choosing Wisely Australia has produced some advice for patients, but more needs to be done to educate them about their best choices.

  • Previous editions of The Health Wrap can be read here.
  • Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe

ICYMI: Reading and resources recommended by Croakey team

• Dr Seye Abimbola, Editor in Chief of the newish journal, BMJ Global Health, explores some of the differences between the fields of international health and global health in this recent article, On the meaning of global health and the role of global health journals. He concludes that while international health focuses on helping lower and middle income countries, global health is about health equity everywhere, including within high income countries, so that it would, for example, include Indigenous health equity in Australia. He writes:

I hope that we can begin to truly decolonize global health by being aware of what we do not know, that people understand their own lives better than we could ever do, that they and only they can truly improve their own circumstances and that those of us who work in global health are only, at best, enablers.”

Interestingly, his article does not address the distinctions and synergies between these two fields and planetary health.

• Jeff Sparrow, writing in The Guardian, draws a powerful comparison between the build up to World War One and the years of inaction on climate change. He writes:

The extraordinary – almost absurd – contrast between what we should be doing and what’s actually taking place fosters low-level climate denialism. Coral experts might publicise, again and again and again, the dire state of the Great Barrier Reef but the ongoing political inaction inevitably blunts their message.

It can’t be so bad, we think: if a natural wonder were truly under threat, our politicians wouldn’t simply stand aside and watch.

The first world war killed 20 million people and maimed 21 million others. It shattered the economy of Europe, displaced entire populations, and set in train events that culminated, scarcely two decades later, with another, even more apocalyptic slaughter.

And it, too, was a disaster foretold, a widely-anticipated cataclysm that proceeded more-on-less schedule despite regular warnings about what was to come.”


Tweets of note

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