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What reforms are needed to ensure Medicare delivers for changing health needs over the next 40 years?

Alison Barrett writes:

In marking the 40th anniversary of Medicare today, health leaders have cautioned that determined reform efforts are vital for ensuring Australia’s health system can meet current and future pressures including climate change and an ageing population.

According to Stephen Duckett, Honorary Enterprise Professor at The University of Melbourne, three key reforms are needed to ensure Medicare can address future challenges: make GP care affordable for all, reduce out-of-pocket costs for blood and imaging tests, and cover dental care.

In The Conversation article – in which the disclosure stated “Stephen Duckett, like all Australians, benefits from Medicare” – Duckett said innovation in Australia’s health system must be based on Medicare’s “founding principles of addressing financial barriers to provide universal and equitable healthcare to all”.

Echoing Duckett’s comments, health leaders surveyed by Croakey also called for universal oral healthcare, as well as for a shift towards preventive and person-centred healthcare and flexible funding models, with one expert predicting that fee for service models would be “derided as an obvious absurdity” in future years.

We invited approximately 30 people and/or organisations in the health sector – including the Department of Health and Aged Care, health policy and economy analysts, public health academics, Aboriginal and Torres Strait Islander health organisations and allied health experts – to share their views on Medicare and health reform.

We received responses from 12 people or organisations, and additional four advised they were unable to provide comment. These are summarised in this and another article to come.

To mark this significant anniversary, Croakey is planning a year-long project – #Medicare40years – to highlight the importance of ‘learning from the past, planning for the future’, to discuss a wide range of health reform issues.

We invite you to join us at an open planning meeting on Zoom on Monday 5 February from 4pm AEDT – registration link is here. Please also use the hashtag #Medicare40Years when sharing related content.

Other events include:

Some of those presenting at these events have shared their insights below. Also read the speech by Health and Aged Care Minister Mark Butler at Deakin University this morning.


Continued improvement needed

Consumers Health Forum of Australia (CHF)

In a statement, CEO Dr Elizabeth Deveny (who is presenting at Deakin University event) said:

When we talk to Australian health consumers about Medicare, they tell us about how much they like their little green card and the certainty it gives them knowing that if they get sick, they can get the help they need.

But what we are also hearing from consumers is that the health system is so complex that they don’t understand everything that Medicare entitles them to.

Medicare’s popularity demonstrates Australians’ support for our universal healthcare system, which should not be taken for granted.

The universality of Medicare is under threat. CHF is concerned by some of the commentary that has emerged in the sector over the last few years which is viewing Medicare as a safety net for the most disadvantaged, and not as a universal access scheme for all. Those that believe in universal healthcare should take note of this and not let our current system be eroded.

Medicare must ensure it can keep up with the changing health needs of Australians. One area we want to see continued improvement in is the support for people with a or multiple chronic health conditions, some of that work is underway but we want to discuss as a sector what more can be done to ensure Medicare remains fit-for-purpose.

We also can’t forget the mouth. The dental system in Australia is not where it should be for a country like ours – how can Medicare be enhanced to help people afford and access oral health?

Read the full statement from the CHF, calling on the Australian Government to fund a public education campaign that fully explains the Medicare system to the general public.


Community health model is the future

Chris Turner, cohealth Deputy Chief Executive

Q: In another 40 years’ time, how do you envisage the health issues facing Australians?

A: In 40 years’ time, we will see many more people with chronic health conditions and conditions related to climate change. We must prepare for this by ensuring we have a robust and accessible system of preventative healthcare available to every Australian.

We also know that for lower socioeconomic and CALD populations, and those experiencing homelessness, the equitable access to safe and high-quality healthcare is already constrained and this will worsen over time if it is not made a priority. Community health is designed to address this need in Victoria, but without sustained dedicated funding to support this model of care, these populations will suffer.

Q: In another 40 years’ time, what is on your wish list for Medicare and our health system?

A: In the future, we want the norm to be the community health model, where all Australians can have their health and wellbeing needs met by a multidisciplinary team of health professionals at centres in the communities where they live. We want people whose needs are deemed complex to get the consistent care tailored to what they want and need.

To do this, we need model of Medicare funding that allows for flexible, blended payments and longer appointment times, and incentivises health professionals to work with people who face barriers to healthcare. This model is the best way to face the health challenges of the future.

• Nicole Bartholomeusz from cohealth is presenting at Deakin’s Medicare event


Universal oral healthcare

Tan Nguyen, National Oral Health Alliance and Deakin University

Presenting at Deakin’s Medicare event today

Q: What are the key lessons to learn from the history of Medicare, to inform future reform efforts?

A: Medicare has largely been driven and dominated by ‘the experts’ and the health professions. It has shown that a fit-for-purpose sustainable public health insurance model need intellectual input beyond the field of medicine, and should include consumers, health economists, and other relevant stakeholders in the conversation. The longstanding absence of essential oral healthcare within Medicare has fundamentally and negatively reinforced the separation of oral health from mainstream medicine.

Q: In another 40 years’ time, how do you envisage the health issues facing Australians?

A: It is well recognised that health is largely shaped by other social determinants, while achieving health tend to be equalised with the delivery of health services. The evidence shows us that health outcomes tend to favour consumers accessing healthcare through integrated team-based models of care. Consumer expectations are also changing, and this is important when considering the delivery of healthcare. Modes for accessing healthcare is also changing, so this should be reflected in our evolving healthcare system.

Q: In another 40 years’ time, what is on your wish list for Medicare and our health system?

A: Eventually Medicare will include essential oral healthcare so that it is universal and available for everyone. But, some people have higher oral health needs, which should be supported by the dental programs funded by the states/territories. I would also like to see flexible funding models introduced to incentivise innovation to capitalise on rapid developments in information technology such as artificial intelligence, and value-based health care payments models that reward outcomes rather than service delivery.

• Tan Nguyen is presenting at Deakin’s Medicare event today


Shift to prevention focus

Scott Willis, National President of the Australian Physiotherapy Association

Q: What are the key lessons to learn from the history of Medicare, to inform future reform efforts?

A: Medicare was revolutionary when implemented and still offers fairness; the current problems are not necessarily in its design but in the lacklustre reforms. These have failed to make Medicare agile, flexible, and capable of driving the required changes, particularly over the last decade.

The shift from reactive models to preventive healthcare is essential, and this will require an element of payment reform. However, the failure here is in a lack of political courage to secure the required transition from a reactive healthcare system based on an episodic, acute care model towards preventive care solutions addressing the causal factors affecting health status.

Universality can only be restored if we address the systemic barriers that prevent us from driving more effective, coordinated and contemporary models of care. This does not necessarily mean more money invested but better utilisation of resources and allowing disciplines to work to their full scope of practice.

Q: In another 40 years’ time, how do you envisage the health issues facing Australians?

A: I think how this future looks really depends on the strength of Minister Butler’s strengthening Medicare reforms.

If we make the required shift toward a more preventive health model, combined with the transitions that allow us to address the barriers, and also enable the health workforce to work to their full scope of practice, then we would expect to see a healthier Australia and a less costly, more efficient model.

Q: In another 40 years’ time, what is on your wish list for Medicare and our health system?

A: With the required transitions made and equity firmly embedded, Medicare might closely resemble the vision of the late, great and honourable Prime Minister Bob Hawke.

We would have secured a healthier population, through Minister Butler’s reforms by activating a more digitally enabled, fairer and efficient healthcare system.


Broaden the scope

Adjunct Associate Professor Lesley Russell, Croakey Health Media member and regular columnist of The Health Wrap

Q: What are the key lessons to learn from the history of Medicare, to inform future reform efforts?

A: Big government social programs (like Medicare) need careful attention, evaluation, and adjustment over time to keep them relevant and ensure they function as intended. That has not happened with Medicare, which is now a fragmented program that does not work well for the sickest Australians and is now far from universal in terms of access and affordability (if indeed it ever was).

Medicare has been hindered from its inception by a failure to define the role of existing healthcare services and private health insurance, by the conscription clause that was demanded as part of its acceptance by organised medicine, by the fact that allied health and dental services are barely included, and by workforce turf fights.

Two other problems occurred over time. MBS reimbursements have not kept pace with practice costs or accurately reflected technological and surgical advances and consequently the constraints that the MBS fees placed on what doctors charge have eroded to the extent that they barely exist. And many of the programs operated by the states have fallen away (for example, community health centres and the National Better Health Program).

The ability to be innovative and to plan ahead with changes to Medicare has been stymied because the LNP Coalition commitment to universal healthcare is lacking and changes in government inherently mean changes in focus, funding and foresight.

Medicare today is a system that, for too many Australians, is difficult to navigate and a struggle to afford.

Q: In another 40 years’ time, how do you envisage the health issues facing Australians?

A: While on one hand the trajectory of obesity and associated chronic illnesses, the mental health crisis, the impact of climate change on health, and growing rates of dementia do not augur well, it is impossible to predict the advances in medicine – including a shift to prevention and early intervention – that could ameliorate these.

One thing is certain: more people will be living longer. But will they be living well (physically and mentally) in their final years?

The good news is that forty years is more than enough time to rework Medicare into a HEALTH care system that pays as much attention to wellness and to illness – in other words, a system fit for the needs of all Australians in 2064.

Q: In another 40 years’ time, what is on your wish list for Medicare and our health system?

A: I want to see Medicare as addressing the health and illness needs of all Australians. That will also mean broadening the scope from medicine, hospitals, pharmaceuticals and diagnostics to the social determinants of health. It also means ensuring that CARING is an integral part of the system.


A vision for Medicare 2064

Professor Martin Hensher, University of Tasmania

Q: What are the key lessons to learn from the history of Medicare, to inform future reform efforts?

A: Even the best systems in the world become ossified and eventually become driven by their own internal logic, rather than the social and policy objectives they were originally set up to meet. While the objective of Medicare is universal health coverage, its basic form is that of a reimbursement system – MBS, PBS and now ABF financing of public hospital services.

Over the decades, healthcare providers (both practitioners and organisations) have strongly optimised their services to maximise reimbursement – with the inevitable effect that efforts to change Medicare to better meet the needs of Australians are typically seen as a threat to revenue streams and livelihoods.

Far too many stakeholders have rationalised and internalised the desirability of Fee for Service payment systems, despite the overwhelming evidence that these are wasteful, inefficient, and inequitable. In particular, Medicare’s privileging of Fee for Service for procedural activities has driven deep distortions in earning disparities and relative attractiveness between medical specialties, which is closely connected to the ongoing crisis in general practice and primary care.

Q: In another 40 years’ time, how do you envisage the health issues facing Australians?

A: Some issues are “baked in” by wider forces which are already ineluctably in motion. In 40 years, there will be more senior Australians relative to workers, and Australians will be older on average, with all that entails. The many health consequences of climate change will be clearly apparent, across the age spectrum. The long-term consequences of today’s epidemics of non-communicable diseases – including mental illness and distress – will still be playing out among the middle-aged and elderly Australians of four decades from now.

We may have made real progress in tackling the commercial, social and ecological determinants of health which are today driving chronic disease and mental distress for so many Australians – really preventing much chronic illness for future generations, and reducing its burdens for those already alive.

Yet this will only have happened if we have been willing to take firm action to thwart those who profit today from products which cause tomorrow’s ill-health, and if we have made real achievements in reducing economic inequalities across Australian society. It is equally possible that the legacies of today’s multiple ecological crises (going well beyond the single issue of climate change) and social and economic inequalities (and their many traumatic impacts on mental and physical health) will make themselves felt in worse population health outcomes in 40 years’ time than those of today, magnifying chronic diseases over coming decades.

Q: In another 40 years’ time, what is on your wish list for Medicare and our health system?

A: I would like to see Medicare 2064 completely reorient our healthcare system towards effective, local, person-centred primary healthcare. Primary care (now incorporating local, community based general medicine, geriatrics, psychiatry, paediatrics etc) will be not only where the vast majority of healthcare workers and doctors work – it will be where they aspire to work.

Fee for Service payments will be a museum piece, derided as an obvious absurdity by health economists and doctors’ leaders alike. For-profit healthcare may or may not still exist – I’m agnostic – but where it does, it will earn significantly lower profits than it does today, and the large differentials in medical incomes that are quietly driving so many of our problems today will be looked on with horror and disdain.

Patients and health professionals alike will seek only to have treated that which is absolutely necessary to treat, and will work with each other – and their wider communities – to minimise the need for healthcare in the first place.


Radical health policy reforms

Adjunct Professor Alison Verhoeven, Deakin University, health policy analyst and Croakey Health Media director

Q: What are the key lessons to learn from the history of Medicare, to inform future reform efforts?

A: Really innovative policy reform is possible and will endure, if it truly improves the lives of most people. Understanding the impact of unaffordable healthcare, and designing solutions that reduced serious disadvantage and benefited most people, were key to Medicare being so well accepted. Also important was the ability to effectively communicate both the problems and the solutions to the electorate.

We also should learn that being slow to change and adapt policy to meet changing requirements results in an erosion of good policy which can be very difficult to reverse.

Q: In another 40 years’ time, how do you envisage the health issues facing Australians?

A: Older, sicker people will be seeking healthcare in a society where there are fewer taxpayers available to fund public health services. New technologies and artificial intelligence will change what is possible, and there will be ever-growing demand for what may be costly personalised treatment plans.

Unless we institute radical health policy reforms that focus on prevention, affordability and accessibility, fewer and fewer people will benefit from the significant technological advances that will be available to us.

Q: In another 40 years’ time, what is  on your wish list for Medicare and our health system?

A: All Australians, now, and in 40 years’ time, should be able to access the best available, highest quality healthcare appropriate to their needs, wherever they live and whatever their circumstances.

A health system which is adaptable and resilient, forward-looking and ready to respond to emerging need, is on my wish list.

• A second article in this series will be published in coming days.

More commentary


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