The federal budget and health: a Croakey survey

In the lead-up to the budget, Croakey has asked an assortment of public health and health policy types about their wishes and expectations.

Michael Moore, CEO, Public Health Association of Australia

In the initial budget for this government was a huge effort on hospital waiting lists and $$$ through to the States for improvements at the tertiary level.

I suspect that this time around there will be an emphasis on workforce development (or there should be).  Primary care is regularly in the Minister’s speeches as another possibility.

Among bureaucrats is a fair bit of talk coming out of the Discussion Papers of the Preventative Health Taskforce and the Health and Hospitals Reform Commission about the possibility of a National Body to look after prevention, health promotion, research – perhaps to do the sort of things that are set out in the goals of VicHealth.  Plans for the National Prevention Agency are already on the public record through the COAG papers.

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Professor Mike Daube, president, Public Health Association

I would hope to see significant changes to the way tobacco and alcohol are taxed.

It’s hard to think of any reason why a government wouldn’t put up tobacco tax. It’s popular – even among smokers if some of the revenue goes back to education and treatment. It’s long overdue – nearly ten years since the last real increase. It’s in line with international trends – Australia is one of the lower tobacco-taxing countries in the OECD. It stops adults and kids from smoking – more than any other single measure. It brings in much-needed revenue. And just as a bonus, it will save lives.

The alcohol tax system has been a mess for many years. The Henry Review is looking at this, but the present Budget would be a great opportunity to start the move towards volumetric taxation, with a special emphasis on the products that are targeted to kids an at-risk drinkers.

Any increase in tobacco or alcohol tax should be accompanied by a significant further allocation to prevention so that it receives more than the current less than 2% of national health spend. We know that there is overwhelming public support for this approach.

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Professor Peter Brooks, executive dean, health sciences, University of Queensland

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Funding for telehealth consultations; increased tax on alcohol, cigarettes and junk food; increased funding for prevention

Q. What do you expect will be the big health announcements in the budget?

A. Some infrastructure projects, funding for Indigenous health projects – long overdue.

Q. What areas in health do you expect will be the losers in the budget?

A. Hopefully pathology and imaging services, and procedural fees.

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Health economist Professor Gavin Mooney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. A costed long term strategy for CTG in Aboirginal health. What has been anounced so far is pathetic.
Revamp of Medicare primary care with increase in capitation for GPs and reductions in ffs. Also more targeted payments for prevention services in primary care.
Program (or clinical) budgeting within tertiary hosoitals to control costs and increase efficiency.
Increased spending generally in keeping people out of hospital
Outside the health portfolio – increased and more progressive income taxation; increased corporation taxes; increased spending on housing for the poor; and increase in salaries for the state sector teachers and other boosts to state education.

Q. What do you expect will be the big health announcements in the budget?

A. More money for hospitals but with attempts to tie to performance indicators (but this will not work)  Increase in charges for PBS items.

Q. Who or what areas in health should be the losers in the budget?

A. Private health insurance premium payers who should have their subsidy withdrawn.
Tertiary hospitals.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Community care
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Mr Robert Wells, Director Menzies Centre for Health Policy, ANU

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A.No further cuts in primary care or prevention.
Some provision to progress the reform process, eg an independent ‘reform commission’.
An attempt to rationalise the private health insurance rebate to get some value for the investment or to reduce outlays for this.

Q. What do you expect will be the big health announcements in the budget?
A. Very few – the timing of the various reports lets them off the hook for this budget.

Q. Who or what areas in health should be the losers in the budget?
A. Private health insurers
Drug companies – more could be done re pricing, esp in the light of the GFC
Pharmacists – either they should be paid less for prescriptions dispensing or do more in primary care
Doctors- there could be some attempt to limit the amount doctors can charge for a service & still claim from Medicare (ie limit the copayment)- courageous stuff but these are hard times & even banking execs are expected to reduce their incomes

Q. Who or what areas in health do you expect will be the losers in the budget?
Probably consumers – there could be savings in the PBS which ultimately will raise prices for consumers
People who need expensive support aids etc to  supplement their medical care are unlikely to see any relief

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Prue Power, Executive Director, Australian Healthcare & Hospitals Association

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. The single most important outcome in this Budget is the allocation of the remaining $5 billion to the Health Infrastructure Fund.   The initial $5 billion of the promised $10 billion was provided in last year’s Budget and the health sector is relying on receiving the full amount promised to fund essential infrastructure projects.  Australia’s health infrastructure is in desperate need of upgrading and revitalising to ensure that our health system can continue to deliver high quality care to the community.  If this funding is not delivered, Australians can expect our health system to become increasingly less able to maintain high standards of quality and safety and to keep up with new developments in health care internationally.

Other initiatives that AHHA would like to see in this Budget include: increased efforts to engage consumers in the planning and delivery of health care; a national approach to data and benchmarking within the health system to improve quality of care across the sector; a range of health information technology and management projects to support better delivery of health care; national leadership on oral and dental health; and  improved service integration, including adapting the innovative “Map of Medicine” to the Australian context.

Q. What do you expect will be the big health announcements in the budget?

A. AHHA is hopeful that the Government will fully meet its commitment of $10 billion in new funding for the Health Infrastructure Fund.  We also hope that the Government will understand the long term economic benefits of investing in evidence-based health care and will allocate funding to the other proposals outlined above.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. If the Government takes a short sighted view in this Budget and does not allocate the promised funding to the Health Infrastructure Fund and other initiatives in order to increase its bottom line, the Australian community will ultimately be the losers.  In particular, the next generation of Australians will suffer the consequences of inheriting a health system that is not equipped to meet the needs of the community and lags behind that of other countries.

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Health policy expert Dr Yvonne Luxford

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Clear dedicated funds to further the campaign to Close the Gap in Indigenous life expectancy, including funds to address the social determinants of health
The creation of a National Prevention/Public Health Agency
A comprehensive suite of alcohol tax policies  with a percentage of income hypothecated to prevention and treatment programs
Funding for school based health literacy programs with regular testing
A scheme to enable salaried GP positions in Superclinics along with salaried allied health workers and salaried public health physicians
Full Commonwealth funding for the Public Health Medicine training program
Funded support for all health professionals to improve their engagement with eHealth
Increase in access and level of funding for students, sole parents, the aged, unemployed and carers.

Q. What do you expect will be the big health announcements in the budget?
A. The creation of a National Prevention/Public Health Agency
A comprehensive suite of alcohol tax policies  with a percentage of income hypothecated to prevention and treatment programs
Restructuring of funding for the GP Divisions

Q. Who or what areas in health should be the losers in the budget?
A. Drinkwise and any similar industry controlled body

Q. Who or what areas in health do you expect will be the losers in the budget?
A. I don’t have a good feel on who will miss out this budget.

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Fran Baum, professor of public health, Flinders University

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. More sustainable long term (10 years) funding for health promotion through a national healthy and sustainable communities project to be led by local government and  local health services – multi-sectoral and community driven
Capital and recurrent funding for multi-disciplinary community health centres with salaried medical and other health professional staff (instead of super clinics) focus on chronic care and health promotion – with local boards of management – supported by training program so these centres can take students from all health disciplines on multi-disciplinary placements
Serious funding for research program on the social determinants of health all aimed at answering question “What creates and sustains health and equity” explicitly not focused on diseases
Scrap private health insurance rebate
Regulate alcohol advertising – i.e. scrap industry self-regulation
Ban fast food advertising

Q. What do you expect will be the big health announcements in the budget?

A. More $$ for hospital waiting lists and treatment of diseases and medical research

Q. Who or what areas in health should be the losers in the budget?
A. Hospital intensive care units
End stage treatment for diseases where there is little hope of recovery and not really in the interests of the patient or society

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Professor Glenn Salkeld, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. I would love to see a national centre for disease prevention and healthy living funded by Treasury and run through the office of PM&C.
I would love to see Education fund a school based program on healthy eating, cooking and physical activity. Get parents involved too.
I would love to see Health and Education get together and come up with real plans for training the next generation of health professionals
in Australia, in our region and in those low and middle income countries that need our help.
I would love to see Sport fund a national insurance scheme which covered the cost of liability and health insurance for all children playing sport.
The cost of club sport is becoming an unnecessary barrier to kids participating in multiple weekend sports.
I would love to see a greater willingness in Health to promote good health – to counter the supply side forces that promote bad health.

Q. What do you expect will be the big health announcements in the budget?

A. Hmmmmm. Given that most of the Health budget is committed to keeping the status quo (to fund recurrent expenditure) I wonder how much
room is left for big announcements in a climate of financial gloom. Any big announcements would have to follow Labor Party commitments
on reform in primary health care, child and maternal services, and the usual technology stuff (like the bionic eye). I’d like to think that
prevention will get a guernsey in the budget but maybe its too early in the life cycle of the Preventative Health Task Force to expect too much
right now.

Q. Who or what areas in health should be the losers in the budget?

A. My son tells me that the TV show ‘The Biggest Loser’ is an essential topic of conversation at school. Overweight and obesity are bound to get
some attention. The real ‘biggest losers’ should be services/procedures/drugs that
provide no gain (health) for a lot of pain (cost).

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Ironically and perhaps sadly I think the losers will be average folk trying to cope with chronic disease, and/or who have a family member
with a disability and/or who live in wrong post code that find access to help, services and support so hard to find. In hard financial times it is so often those who have the least who are asked to sacrifice so much. On this I would be delighted to be proved completely wrong!

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Health policy analyst Jennifer Doggett

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Whether or not the government allocates the remaining money for the infrastructure fund, as promised, has to be the main health-related issue in this budget.  any other small buckets of money thrown around will be insignificant if they effectively cut $5b from what has been promised for health infrastructure.

Q. What do you expect will be the big health announcements in the budget?

A. No idea – heard the rumours about the Medicare safety-net but not sure how reliable they are. Cutting the safety-net would make sense and probably not alienate much of the government’s core constituency so it’s a fair bet.

Q. Who or what areas in health should be the losers in the budget?

A. As always, stopping inefficient and regressive practice of subsidising PHI through the rebate.  The saved $ could be much better used elsewhere in the health system or simply handed back to consumers.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. If they cut the Medicare safety-net, some of the medical specialists will be the losers, particularly obstetricians and those who have the capacity to move their care from the hospital to community setting.

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Dr Lesley Russell, Professor Stephen Leeder, Menzies Centre for Health Policy, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A. That there has been no diversion from or  dimunition in the commitments made on health care reform and closing the gap
on Indigenous health. As President Barack Obama has clearly demonstrated, health care reform is an essential part of the armament needed to tackle the impact of the global economic crisis, and we cannot resile from the timely implementation of commitments to our Indigenous peoples.

Q. What do you expect will be the big health announcements in the budget?
A. No big announcements. Expect lots of small program cuts as the ERC goes looking for savings and everything else on hold, pending reports.

Q. Who or what areas in health should be the losers in the budget?
A. It should not be about who loses but about making policy changes that will ensure some areas and programs work more effectively and equitably. Is there the will and the policy grunt to do this?

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Publicly funded community health care

Public health, especially programs to tackle obesity/nutrition/urban environment/physical activity

Transition, step down care for the mentally ill and their carers

And some concern about funding for rural health programs, which have apparently been reviewed by DOHA, but no publicly available report of this review.

Real and realistic efforts to coordinate health care and associated needs (travel, medical aids, oxygen etc) and ease out-of-pocket costs for the chronically ill.
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Boyd Swinburn, professor of population health, Deakin University
The government should be recouping its lost reserves by significantly increasing the taxes on alcohol, tobacco and junk food with a significant proportion of them allocated for prevention and the promotion of healthy patterns of consumption – as suggested as the top priority in the 2020 forum more than a year ago I think.

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Dr James Gillespie, Deputy Director, Menzies Centre for Health Policy, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A. Nothing earth shattering. It would be nice if a government waited to see what its inquiries into the system report before making major changes.

Q. What do you expect will be the big health announcements in the budget?
A. Very little. Continue the drift  of risk from government and insurance onto out-of-pocket by fiddling with co-payments to save a bit of money and, less likely, cutting the PHI rebate. More likely they’ll freeze this as it means (technically) no broken promises.

Q. Who or what areas in health should be the losers in the budget?
A. Higher income earners’ rebates.

Q. Who or what areas in health do you expect will be the losers in the budget?
A. Some of the higher cost diagnostic areas – imaging etc…. where there is a fair suspicion that corporate business plans are gaming Medicare.

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Consumers Health Forum

Our budget wish list: We see these will continue the momentum from the reform process and the 2020 summit with practical, implementable changes that will lead to better health outcomes for consumers.  Funding these items will see Govt rhetoric turned into reality.

• E-health – national electronic health records and e-initiatives to bring equity of health care to rural and remote area
• Implementation of the reform process – particularly in relation to the primary health care strategy, preventative health taskforce and the health and hospitals reform commission.
• Funding to resource consumer representatives to take part in the reform process and other committees that make decisions about health care in Australia.
• National Registration and Accreditation Scheme – including resourcing for the community representatives to have effective input
• Taxes (preferably increased) on alcohol and cigarettes to be channelled directly into health services and prevention/wellness campaigns
• Safety and Quality Commission – to implement the S&Q recommendations, including the hospital reporting

What do we expect?

• Beyond the Swine Flu, we have no confirmed expectations. However, we hope the budget will focus on the above.

What should lose?

• Systems that don’t work for consumers.

What do we expect will lose?

• Given the rumours, we expect that – unfortunately – radiology, pathology and IVF will lose

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Other comments from sources who did not want to be identified:

Anon 1: “I don’t expect much in the way of new initiatives as the big reform agendas are some way off and hard for the government to make commitments at this point. Maybe the Preventative Health Agency but not an expectation I have. Maybe some increases in taxes on alcohol and tobacco. Mental health ??? I do expect more reforms of disability employment which will continue to improve prospects for those with mental illness. But this is against a very different employment context.
Losers we need to see – I hope we see the end of the safety net and some winding back of the Private Health Insurance – but the latter is unlikely. They will have plenty of other areas of middle and upper class welfare to cut before going to this almost sacred cow. I would like to see changes to Better Access (cut the GP mental health plan rubbish) and curtail the growth in psychologists (the common garden variety who represent the least trained and charging the highest OOP expenses). Like to see much more incentives toward collaborative PHC practice,
Losers I expect – safety net, not much else, maybe PBS will have some further limitations.
I think in health we are waiting for regime change.
Indications are that they will take major reforms from the papers under development to the next election and continue to try and hold the current arrangements up for the time being.
I hope I am wrong.”

Anon 2:
Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Some more MBS and non-MBS money for primary health  care, skewed to low spending areas, but also allowing GPs to be fundholders  for more allied health care for chronic ill people; agreement in principle to  Commonwealth Indigenous health services purchasing organisation; also some  extra for AIHW for regional health information including health status,  spending and services

Q. What do you expect will be the big health announcements in the budget?

A. Not much, essentially a ‘let’s wait on the NHHRC  final report and the COAG working parties’

Q. Who or what areas in health should be the losers in the budget?

A.  Extension of cost-effectiveness application, resulting in higher co-payments for less effective and less important  pharmaceuticals and services (eg drug-inducing stents, in vitro  fertilisation); abolition of the Human Services portfolio and re-allocation of Medicare Australia to the health portfolio and Centrelink to the FACSIA  portfolio; increase in MBS safety nets; changed bond arrangements for  residential aged care; sale of Medibank Private

Q. Who or what areas in health do you expect will be the losers in the budget?

A.    Not much if anything.

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Anon 3:
“The abolition of  the $6 bn private health insurance subsidy would be a major contribution to  budget savings. This is not a health program. It is a subsidy to financial  intermediaries like Merrill Lynch.  PHI is grossly inefficient (double the cost of  Medicare administration) inequitable and weakens Medicare’s position as the  major purchaser of services. The alleged claims to take pressure off public  hospitals is misplaced. It has just not happened.

The government and the  private health insurance industry claim that the subsidy is only $3.8 b. In  addition to that sum, there is almost another billion dollars in tax concessions for those who take private insurance. Further, government and PHI estimates of the subsidy have been consistently understated. If the  government is prepared to introduce a cap or a means testing of the subsidy,  it would be a useful start.

Be careful about the argument that the minister  and PHI executives use about choice. The principle of a single payer can  promote choice. There is no reason why Medicare or as in the case of  Veterans’ Health, the single public insurer cannot pay money direct to  private hospitals probably through a DRG formula.

Other proposals – for introducing the second stage of increased generic prescribing  for pharmaceuticals and rigorous regulation of radiology and pathology – would all be very welcome.

A major problem with government health policy  is that it is so piecemeal. There is no ‘health system’. There is focus on  the cost of particular services, eg pharmaceuticals, radiology, etc, but  health care in general is not held accountable for what it produces. I  suggest that the Productivity Commission be tasked to advise the government  on ways to improve the efficiency and productivity of the health sector.

For example, there are variations in the pattern of clinical practice right across the country. These variations are never examined and very little  action is taken on them. I would suggest there are very substantial savings  to be made in this area. The variations in the incidence of caesarean  sections across Australia are an example of the sorts of variations that  need addressing.

Over-utilisation is widespread and unchecked. It is also likely that there is under-utilisation by the poor, indigenous and people  living in remote areas.

The government-appointed commission to review health  services has produced a very timid report. There is also an obvious conflict  of interest because of its relationship with the private health insurance  funds. How else could one explain its draft recommendation to fund dental  care through a tax levy which would then be churned through private health  insurance funds? It is just a crazy idea. The rigour and professionalism of  the Productivity Commission is essential if we are to reduce costs and  improve productivity.

One area which I hope the government will address  in the budget is to commence a rationalisation of co-payments.  The co-payments lack logic and  consistency between programs. Australians are much more wealthy than they  were over 30 years ago when Medicare was introduced. Most of us can afford  to pay more. A good co-payments scheme would ensure that individuals take  more responsibility for their health decisions.

If the government wants  to save money in health, it should offer to establish a joint health service commission with any state that will agree.This is the most useful way forward on both  policy and political grounds to resolve the waste and inefficiency of the  Commonwealth/State divide.

The Commonwealth government has pledged  substantial increases in funds to state public hospitals. I am not sure that  it has insisted on increased productivity on the way these funds are spent.  The government had previously highlighted the importance of activity or  episode funding  being made available on the basis of output) rather  than grants to the states to enable them to continue in their inefficient  ways.

If the government wants to get more efficiency in the  health sector and contain escalating costs, it must address some of the  issues mentioned above.”