Time to rebirth Medicare?
30 September 2009
One recent Sunday afternoon, after several weeks of feeling poorly, I made the uncomfortable transition from being an observer of the health system to a user of it.
As I took off my clothes, put on the green gown provided by the hospital, and followed the instructions for having an X-ray, I felt terribly vulnerable. Was this going to be one of those moments in which everything changes?
Fortunately, my fears were groundless, and I was soon restored to my usual sense of self. But the unsettling experience was a timely reminder of why health policy - an area often obfuscated by impenetrable jargon and self-interested powerbrokers - matters so much.
Even if you find health policy debates mind-numbingly dull - as news editors have been complaining in the United States, where even the Obama factor is not enough to stop audiences switching off - there will come a time when they are suddenly, awfully relevant.
And so it is worth at least trying to have a conversation about healthcare policy that moves beyond the usual predictable claims and counter-claims, because it has become abundantly clear that things cannot continue as they are, at least not if we want affordable, accessible, quality care. Another reason for having this conversation, apart from matters of naked self-interest, is that what we want from our health system says much about what we value as a society. Do we really value a fair go for all?
For all its flaws, the final report of the National Health and Hospitals Reform Commission offers an opportunity for this conversation. And one of its most controversial suggestions, that we move to "a next generation of Medicare," involving managed competition between health funds, merits careful examination.
It's unfortunate that the commission suggested this new model be called "Medicare Select," a name that reinforces fears that universal coverage will be eroded, when that is not what it is proposing. In one sense, though, these fears are something of a furphy anyway. Our current system provides "universal" cover in theory rather than practice, and does quite a good job of upholding the "inverse care law." Coined by English GP Julian Tudor Hart in 1971, this law states that those with the greatest need for care are least likely to get it.
Think, for example, of how poorly the current system serves Indigenous Australians, people with mental illness or other complex needs, and people from the bush, the outer suburbs and other areas not favoured by health professionals. Think too of the lottery of hospital waiting lists, the GP practices that have closed their books, and the differences in the care afforded to some patients versus others with the same conditions, and it soon becomes apparent that our so-called "universal" system is forced to ration healthcare, albeit in ways that are often irrational.
Inequities like these have increased over the past decade thanks partly to federally funded incentives for private health insurance, which have tended to benefit the better-off and help skew the system in favour of procedural medicine (when we should be skewing it in favour of primary care if we want to improve equity, access and outcomes). Even the National Health and Hospitals Reform Commission's report noted "increasing concerns that a two-tiered health system is evolving."
Some observers were also quick to assume that the Medicare Select proposal signalled a shift towards a US-style privatisation, when in fact it was countries on the other side of the Atlantic, with a far greater sense of social solidarity, that provided the inspiration.
The proposal is similar to measures introduced in the Netherlands in 2006 - measures that have also been floated as a possible model for reform in the United States and elsewhere. Holland now requires all adults to buy health insurance, with children insured for free.
Health funds are paid from both the public purse and private contributions, and are paid more by the government for taking on people likely to have poor health. Low-income families can apply for a subsidy, and more than 50 per cent of Dutch households received such assistance in 2008. All insurers must offer everyone a government-defined policy, which covers primary, inpatient and outpatient care and is updated annually. Only limited dental and allied healthcare is included in this, but people can pay extra for supplementary policies.
And the system does seem to be very concerned with ensuring fairness. According to a recent British Medical Journal article describing the reforms, "The Dutch live below sea level behind dykes, and history has taught them that solidarity pays off. This solidarity has built a healthcare system that treats all alike. There is little difference in the use of care between people with different educational levels or ethnic backgrounds after differences in need have been taken into account."
Read the full piece here at Inside Story.
Melissa Sweet is a freelance health journalist who has an honorary appointment in the School of Public Health at the University of Sydney.
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