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The Health Wrap: voting for health in lutruwita/Tasmania, spotlight on bulk-billing rates, plus steps forwards – and back – for women’s health

Writing from Colorado, Adjunct Associate Professor Lesley Russell examines the health policies on offer for voters in lutruwita/Tasmania, noting a stark contrast between those being put forward by political parties and candidates, and those nominated as important by Health Consumers Tasmania.

The column also takes a deep dive into bulk-billing rates in general practice, raising questions about the costs of running practices, and looks at grief, loss and youth incarceration.

The quotable?

Those fighting for women’s reproductive health rights in the United States and around the world have been buoyed by the French Government’s pioneering push to become the first country in the world to enshrine abortion rights in its constitution.”


Lesley Russell writes:

Greetings from Colorado where the snow continues to fall – in stark contrast to the dreadful wildfires in Texas.

This week, as US citizens, we voted in the Colorado Democratic primaries and it’s fair to say that we have been anxiously following these early days of the US presidential elections.

Voting on Super Tuesday was a very low key affair. I did get a tiny sticker that said ‘I voted’, but there was not a democracy dog, or even a hot dog, in sight.

There’s lots of political news, much of which is very depressing.  Thank goodness we can clear our minds with skiing and snowshoeing!

From democratic duties to snowshoeing at Acorn Creek, Summit County. Gore Range in the distance.

#TasVotesHealth2024

As we head towards the 23 March election in lutruwita/Tasmania, here’s an update on the health issues put forward by the major political parties.

But first, here’s the Liberals’ 2030 Strong Plan for Tasmania’s Future – which, amazingly, doesn’t seem to mention health (or education) anywhere.

In the accompanying call to vote, Premier Jeremy Rockliff does mention health and the fact that his government has provided an additional 298 hospital beds and employed an extra 2,500 health professionals including 1,390 nurses.

At the Liberals’ official campaign launch last week, Rockliff sought to address what many see as one of Tasmania’s biggest problem: a health system in crisis, with GPs in short supply, hospitals under pressure, and serious problems with Emergency Department ramping.

Here is what the Liberals have said they will do to address these issues:

  • Double the size of the emergency department of Launceston General Hospital, with construction to begin in 2025
  • Provide a number of new buildings, wards and specialist service units at the North West Regional and Mersey Community hospitals at a cost of $175 million
  • $187 million in capital upgrades at the Royal Hobart Hospital
  • Recruitment of 44 doctors and 25 nurses at the Royal Hobart Hospital
  • What is described as a “ban” on ramping via a directive that would require that patients arriving at hospital by ambulance must be transferred to emergency department doctors within 30 minutes
  • The state would attract up to 40 new regional and rural GPs by paying $100,000 off their university HECS fees
  • A “GP Now Rapid Response Team” of 10 state-employed GPs to be deployed at short notice to regions where a shortage emerged, such as through a sudden practice closure.

Here are the Labor health commitments:

  • Establish a fund to upgrade regional hospital infrastructure, include 24/7 emergency care for regional and rural hospitals
  • Free university degrees for 150 health workers, to work at local hospital for three years
  • Retain private maternity services in the state’s North-West, conduct a statewide review of maternity services
  • Upgrade six regional ambulance stations
  • Amend Launceston General Hospital master plan to include new, additional childcare services
  • Guarantee no payroll tax will apply to a General Practitioner.

And here are the Greens’ health commitments:

  • Hire 87 new full-time paramedics by June 2025
  • Recruit 30 new ambulance staff per year for five years, recruit 25 clinical educators and 50 clinical coaches by 2030, 120 new nurses per year until 2030, fund 10 new positions for psychiatric emergency nurses
  • Six new ambulance stations, upgrade 13 others
  • Establish Mother and Baby Service as community day program and residential stay service
  • Establish Alcohol Tobacco and Other Drugs Unit, new public withdrawal management and rehabilitation beds
  • Expand public perinatal mental health beds to 12
  • Expand community-based preventative health grants to $5 million per year
  • 24/7 on-site radiology and pathology services at the LGH
  • Pill testing at events and festivals, permanent testing facilities
  • Free smoking cessation products in GP clinics.

These were taken from the ABC News Tracker of Liberals, Labor and Greens election pledges to Tasmanians. I was unable to find any Tasmanian election commitments from the Jacqui Lambie Network .

The health priorities from Health Consumers Tasmania – many of which acknowledge the social and economic determinant of health – are here. They make quite a contrast with those of the political parties.

Also see this statement by health groups urging greater investment in prevention, including a dedicated budget for preventive health.

https://www.ama.com.au/articles/ama-tasmanias-five-election-priorities-improve-health-care
https://www.abc.net.au/news/2024-03-06/tasmania-political-donation-laws-weakest-2024-state-election/103543048

Also see this recent Croakey article: Amid election fever, a call to stop using Tasmanian children “as political pawns”, by Adrienne Picone, CEO of Tasmanian Council of Social Service (TasCOSS), which also highlights the importance of greater investment in prevention. Bookmark this link to follow Croakey’s coverage of #TasVotesHealth2024.


Truth-telling and treaty

It was interesting to read this interview with Jeremy Rockliff when he first came to the job as premier in July 2022. Then he was described as “the nice guy of Tasmanian politics thrust suddenly into the state’s top job”, the “rainbow premier” with an ambitious, progressive reform agenda.

But, the article asked, “Can this straight-talking Liberal moderate pull it off?”

I was interested, even excited, when he promised to continue former Premier Peter Gutwein’s commitment to a truth-telling process and treaty with the state’s palawa/pakana community and pledged a ban on transgender “conversion therapy”.

An Advisory Group to guide the truth telling and treaty process was established in late 2022, and its inaugural meeting was held in February 2023, but it’s not clear what work has been done and what progress has been made.

A tuylupa tunapri palawa community delegation was formed in July 2022 in response to concerns the Government was not hearing directly from the palawa community – as opposed to organisations – in developing treaty and truth-telling.

You can read more in this article from May 2023 here.

Rockliff did support a Yes vote for The Voice.  But he has ruled out Tasmania introducing a state-based Voice to parliament akin to what South Australia is doing.

Labor has stated that it is committed to the current Indigenous treaty and truth-telling process.

The Greens have committed to:

  • Supporting a “respectful and effective” model for Indigenous treaty and truth-telling.
  • Reform legislation to protect Indigenous heritage, introduce new reserve tenure for land returns.
  • Establishment of Indigenous seats in parliament.
  • Commencing an Indigenous-led process to create memorial to warriors and victims of Frontier Wars.

What is happening with bulk-billing services and clinics?

In an intriguing coincidence we recently saw two articles, in the same week, about the rapid decline in the number of general practice clinics that bulk-bill all patients.

The Guardian led off with an analysis of data from the Healthdirect service finder GP database that was done by federal electorates.

It found that found that in the past year to February 2024:

  • 455 GP clinics switched from fully bulk-billing to a mix of bulk-billing and out-of-pocket fees
  • There was an increase of 301 GP clinics listed as charging out-of-pocket fees
  • 114 bulk-billing clinics are no longer on the register, having either closed or been removed for other reasons
  • 124 clinics switched from mixed billing to fully bulk-billing
  • 35 new dedicated bulk-billing clinics were added to the register.

The article includes a figure showing the percentage of dedicated bulk-billing GP clinics in each electorate (as listed on the Healthdirect service finder), as well as the change in the percentage of clinics between 2023 and 2024.

Some electorates experienced an almost 30 percent decline in dedicated bulk-billing clinics in that 12 month period.

[With reference to the previous section on #TasVotesHealth2024: Tasmania (along with the ACT) has the lowest percentage of bulk-billing-only GP clinics. The electorate of Franklin has no bulk-billing-only GP clinics listed in 2024 although there are at least 11 GP clinics listed that offer discretionary bulk-billing.]

There are some comments from me towards the end of this article:

“The way Medicare is currently operating, and what this data highlights perfectly, is how the universality of Medicare has been undermined.

“While the cost of operating a general practice has gone up, there is no publicly available data to show by how much. But it’s pretty clear that the doctors themselves now feel dramatically less constrained about what they charge now than they used to.

“It seems that clinics reflect what other clinics in the area are doing … and that’s perhaps why you see that area around Newcastle and Adelaide with decreasing bulk-billing [clinics].”

I also said there is a possibility that more corporations moving into the ownership of private practices could be part of why there are decreasing rates of universal bulk-billing – although I admit I have no evidence for this.

The Guardian article was followed just a few days later by an analysis of bulk-billing clinics in New South Wales by The Sydney Morning Herald. This analysis, again by electorate, used data from the online healthcare directory Cleanbill, which surveyed 6,818 GP clinics at the beginning and end of 2023 to determine whether they bulk-billed all their general patients.

However, the data does not make clear whether the remaining clinics offer some or no bulk-billed services, or how many patients faced out-of-pocket costs.

It found that, at the end of 2023, NSW had 169 fewer fully bulk-billing GP clinics than at the beginning of that year, due primarily to doctors in Sydney’s middle-income suburbs moving to charge gap fees.

The biggest year-on-year changes were in several suburban Sydney electorates – Cook, Barton, Bennelong, Macarthur, Mitchell, Bradfield and Reid – where more than 20 percent of clinics had stopped bulk-billing all their patients. (See also this earlier article from April 2023)

There’s lots more very interesting and useful data on GP bulk-billing and out-of-pocket costs on the Cleanbill website.

The Federal Government also has bulk-billing data which looks at the proportion of GP services that are bulk-billed, as well as the proportion of patients who have all their services bulk-billed, by Primary Health Network.

In the December 2023 quarter the GP bulk-billing rate for all patients was 76.5 percent. The average out-of-pocket cost for those Australians who were not bulk-billed was in excess of $40. (See also this article from February 2023.)

How does all this measure up against the Albanese Government statements that, following the tripling of incentives paid to doctors who bulk-bill children under the age of 16, pensioners and Commonwealth concession card holders (the incentive has risen from $6.85 to $20.65 in metropolitan areas, and from $13.15 to $39.65 in very remote areas), bulk-billing rates are once again increasing?

First, these two bulk-billing issues are not congruent. it’s the difference between services that are bulk-billed and patients who are bulk-billed. Second, while the national bulk-billing rate has begun to rise, so far this increase is small (2.1 percent nationally between October and December 2023). And third, the incentives do not help many patients who still struggle to afford a GP visit.

It remains to be seen whether the increase in bulk-billing incentives and 58 new  bulk-billing urgent care clinics will help with affordability.

The early signs are not encouraging.

In November the Royal Australian College of General Practitioners reported that the proportion of GPs bulk-billing all of their patients had halved over the course of just one year, and that many doctors won’t change their current approach to bulk-billing despite the new incentives.The data that report on bulk-billing rates and out-of-pocket costs ignore those people who never get to see a GP. That seems to be a growing proportion of Australians.

The most recent data from the Australian Bureau of Statistics (November 2023) reveals 7.0 percent of people who needed to see a GP in 2022-23 delayed or did not see one when needed due to cost. This was double the number compared to 2021-22 (3.5 percent).

An article by Martyn Goddard in The Policy Post highlights the problems with the current focus and the Albanese Government’s number crunching:

The average national bulk-billing rates for services in the Financial Year 2022-23 was 80.2 percent. The Health Minister highlighted the 2.1 percent increase from October 2023 (75.6 percent) to December 2023 (77.7 percent) – but the December figure is actually a 2.5 percent drop when compared to the previous year.

Analysis of Medicare data shows that GP visits are down 37 percent in the period May 2022 (when the Albanese Government was elected) to the end of 2023. (And no, you can’t blame COVID-19 for that).

It’s worthwhile highlighting that this decrease results in significant budget savings for the Government (although if sick people are not getting care we can argue that these are only short-term savings!).

Goddard also suggests – and provides data to support his case – that, contrary to endless media reports, people who can’t afford to see a GP are not ending up in the Emergency Departments of public hospitals. In 2022-2023, the number of non-urgent presentation in EDs was 17.6 percent lower than the pre-pandemic average.

He attributes this decrease (worst in states like Victoria and Tasmania with the greatest pressures on public hospitals) to the very long ED waiting times.

Goddard concludes: “if people are not going to the GP, and not going to emergency either, there is only one possible conclusion: very large numbers of Australians are not getting the medical care they need from anyone.”

As I have regularly pointed out, and in fairness to GPs, it is very clear that the costs of operating a practice (especially if it is trying to provide a range of primary care services) have increased substantially. But we know little or nothing about how or why and what might be done to alleviate these costs.

Back in 2015 Jennifer Doggett and I were making the case that we needed to better understand these business costs if we wanted to address out-of-pocket costs.

In this week’s edition of The Zap, Charles Maskell-Knight has a quote from a Kings Fund report on addressing the decline in National Health Service productivity that highlights another place where GPs might look for relief:

Ask a clinician about waste in their service – the things that waste their time, that waste their patients’ time, and that waste taxpayers’ pounds – and you will see them light up with ideas on ways to improve how services are run.”

I was recently interviewed on ABC Sunday Extra on these issues. You can access the interview here.


IVF now caught up in the anti-abortion rulings in the United States

I have several times written for The Health Wrap about the issues women and their healthcare providers in the United States are facing in the aftermath of the US Supreme Court overturning Roe v Wade and thus abolishing the federal right to abortion. This now extends to the ability to access timely care after a miscarriage, medical abortion and contraception, and – most recently – in vitro fertilisation (IVF).

The Alabama Supreme Court recently ruled that frozen IVF embryos are “extrauterine children” under the state’s statute that allows recovery of damages in civil actions for wrongful death.

This ruling is already having far-reaching implications in the state and beyond, and will be a significant issue in the upcoming presidential campaign. Several clinics that perform IVF in Alabama have suspended their work.

It’s posing quite a problem for Trump and those conservative Republicans who have celebrated the long-held goal of anti-abortion activists to overturn Roe v Wade only to now find that it does not play well with voters, especially women voters.

Those politicians have reason to worry, in an election year, about preventing would-be parents from fulfilling their dreams by blocking a method that polling shows has the support of 85 percent of respondents generally and 78 percent of people who say they are pro-life. Today, this procedure accounts for 2 percent of births nationally.

The White House condemned the ruling, and even issued a statement from President Biden himself.

Not surprisingly, there has been a mad rush to enact legislation to address the Alabama court decision, both in Alabama, in Republican states and in the Congress. To date these efforts have not been very successful.

Democrats have seized on the Alabama decision as more evidence that reproductive rights are under assault and will continue to be so with the current composition of the US Supreme Court, aggravated further if Trump should win the presidency again.

Those fighting for women’s reproductive health rights in the United States and around the world have been buoyed by the French Government’s pioneering push to become the first country in the world to enshrine abortion rights in its constitution.

Lawmakers from France’s upper and lower houses of parliament met on Monday, March 4 and easily passed the historic amendment. The bill was approved in an overwhelming 780-72 vote, and nearly the entire joint session stood in a long standing ovation.

The amendment to Article 34 of the constitution would explicitly enshrine “a woman’s guaranteed freedom to have recourse to an abortion”.

Macron announced after the vote that the amendment would be inscribed in the constitution on Friday, March 8 – International Women’s Day – in a sealing ceremony that is reserved for the most important laws (see more here).


Youth incarceration and bereavement

I was watching a segment on the PBS New Hour about bereavement and the need to acknowledge this better, and it mentioned that a significant number of young people in prison had recently faced bereavement.

This caught my attention and I found some studies from the United Kingdom and the United States that looked at this issue. Perhaps these will be interesting to those who work in this area.

A US paper on grieving youth in the justice system sees grief – a physiological and psychological response to loss – as an often overlooked as a contributor to decision-making and the many ways that youth respond to loss can influence behaviours that land them in the juvenile justice system.

It cites some statistics that are quite staggering. A Chicago study found the prevalence of loss due to death to be 88 percent for detained adolescents, while another in San Diego found the prevalence of loss to be 71.9 percent.

A detailed study of the prevalence of loss due to death and its association with mental disorders in detained adolescents in Chicago found almost 90 percent had experienced the loss of an important person. Mostly this had been sudden loss or loss due to violence.

Minority youth and girls were at particular risk. Youth with any loss or multiple losses were more likely to have mood and behavioural disorders. These factors were linked to higher levels of dangerous behaviours such as fighting, truancy, substance abuse, risky sexual behaviours, and gang involvement that could lead to detention.

A paper for the UK Centre for Crime and Justice Studies states that young people involved in offending have experienced parental, multiple and traumatic deaths at a higher frequency than in the general population.

The paper includes a study of 33 young men aged between 16 and 20 who were surveyed about their bereavement experiences. It found that 30 (91 percent) had experienced at least one bereavement, with the average around six bereavements each. Traumatic bereavements (such as those caused by murder or suicide) were common and experienced by more than three-quarters of the young men.

This led to anger, guilt, acting out, self-medication and violence. The realities of prison life interrupted all aspects of the grieving process and presented a challenging environment in which to deal with the pain of bereavement. The study is written up in detail here.

I wondered about the applicability of these findings in Australia, and specifically whether there are links between grief and the disproportionate incarceration of First Nations youth, many of whom are suffering from loss of culture and self-esteem, intergenerational trauma, and often are grieving family members and friends who have died too early and too suddenly.

My research did not turn up any information about grief and bereavement as a causal factor for the incarceration of youth (including, specifically, First Nations youth) in Australia. Enormous grief and loss are associated with colonisation, however, and incarceration is one of the historic and ongoing strategies of colonisation.

The Australian Law Reform Commission report, Pathways to Justice – Inquiry into the Incarceration Rate of Aboriginal and Torres Strait Islander Peoples (from 2018) has a chapter on the Social Determinants of Incarceration.

Grief is not mentioned here, although there is reference to the high levels of psychological distress experienced by Indigenous Australians. (The 2018–19 National Aboriginal and Torres Strait Islander Survey showed that 31 percent of Indigenous Australians aged 18 and over had high/very high levels of psychological distress, up four percentage points since 2004–05.)

However, I did find a paper written for the Bugmy Bar Book (for use by NSW Public Defenders) that outlines the Significance of Funeral Attendance and Sorry Business for Aboriginal and Torres Strait Islander Peoples (with a specific focus on those in prison).

A beyondblue website page on the risk factors that affect the social emotional wellbeing and rates of depression among First Nations Peoples lists widespread grief and loss and unresolved trauma as significant risk factors.

This page also lists the protective factors that include: social connectedness and sense of belonging; connection to land, culture, spirituality and ancestry; and passing on of cultural practices.

This is not my area of expertise, but it does seem that recognising and addressing grief and loss as a factor in youth misbehaviour and subsequent interaction with the criminal justice system could contribute to Closing the Gap in several key areas.


The best of Croakey

It’s time-consuming and not easy to keep up with developments in health/healthcare and related areas, especially if you have a broad focus and one that extends beyond Australia.

Croakey Health Media has a great new weekly catch-up – The Zap, collated and annotated by the mighty efforts of Charles Maskell-Knight.

Don’t miss it, or you will miss out on a lot.


Good news in Indigenous health

A paper which was published in the International Journal of Environmental Research and Public Health in January 2024 looks at the success of the Strong Born Campaign to address Fetal Alcohol Spectrum Disorder (FASD) within Indigenous communities.

The campaign uses a strengths-based and culturally sound approach with the National Aboriginal Community Controlled Organisation (NACCHOs) working closely with the Aboriginal Community Controlled Health Organisations (ACCHOs) to develop the campaign through co-design. Since the campaign launch in February 2022, tool kits have been disseminated to 92 ACCHOs across Australia.


Another good news story

This story should get you dancing!

The Dance Your PhD competition challenges scientists around the world the explain their research through interpretative dance.

All the latest winners in the various categories are here. The overall winner was Dr Weliton Menario Costa, an ANU academic, for his dance video explaining his work on kangaroos for his PhD in ecology.

You can read more and access his Priscilla Queen of the Desert meets serious scientists and kangaroos dance video (Roo Hip Hop?) here.

And also see his 2021 thesis, Personality, social environment, and maternal-level effects: insights from a wild kangaroo population.


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

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