Mr STEPHEN SMITH (3:37 PM) —Yesterday and today during question time, we have seen the Prime Minister tear up Medicare and tear up bulk-billing. We have seen him indicate the government's intention to turn Medicare from a universal health care system to a system that will be dependent upon a person's wealth and income—that is, based on wealth, not on health. The Prime Minister is clearly flagging that the government would like to restrict bulk-billing to pensioners, low-income Australians and concession card holders.

You need to understand the history to fully appreciate what he is actually on about. During question time today and yesterday the Prime Minister was very happy to return to Dr Blewett's speech of 1984, when Medicare was introduced, and to try to craft from that speech the idea that somehow bulk-billing was only ever intended for pensioners, low-income earners and concession card holders. The truth is that as we, in the course of the next few days and weeks, remember the 20th anniversary of the election of the Hawke Labor government, we remember that one of the things that government is greatly appreciated for—both in terms of fundamental social change and fundamental public policy change—was the introduction of Medicare which provided Australia with a universal health care system. Medicare was based in many respects on Medibank, which the Whitlam Labor government introduced in 1974 but which the Fraser government from 1975 on systematically set about dismantling. Let us understand the correct historical starting point and the public policy importance of these matters.

I could understand if Dr Blewett was most aggrieved at the misrepresentations that have been made about him by the Prime Minister in terms of his intention as the Hawke government's health minister so far as bulk-billing and Medicare were concerned. I will not quote at length but, if you go back to Dr Blewett's second reading speech when he introduced the Health Legislation Amendment Bill in 1983 to establish Medicare, you will see that he said: `What Mr Fraser bequeathed this country was a health scheme lacking in both universality and fairness.' He talked about being proud of the fact that `the principles of the Medicare plan are similar to those of Medibank as it was originally introduced in 1975'.

He drew attention to some of the important differences, but he made the point:

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And he went on. The whole basis of the introduction of Medicare was to establish a universal health care system that would be available to all Australians. All Australians would have access to quality health care irrespective and independent of their wealth. I mentioned that Dr Blewett might be aggrieved by all of this, and he sent me a message in the course of the day saying that bulk-billing was in fact intended for everyone.

There are very good reasons why you cannot mount the argument that universality of access does not mean that we have to have 100 per cent bulk-billing. There is a very fundamental principle here: just because you do not get 100 per cent of the outcome does not mean that the principle of universality is not there. Universality means access to Medicare and bulk-billing; it means that is not determined by a person's income. It does not matter whether there is a Howard government or a Hawke government, the Commonwealth cannot guarantee 100 per cent bulk-billing by way of outcome. You cannot guarantee that every transaction under Medicare will be a bulk-billed transaction. Why is that? The Medicare scheme respects two things: firstly, the Constitution, which says you cannot conscript, direct or require doctors to do things in a particular way; and, secondly, a fundamental part of Medicare being choice by doctors and choice by patients. The whole basis of the introduction of Medicare was universality of access, and bulk-billing was very much an important part of that.

The Prime Minister likes to go to that part of history and say, `Here are the reasons why bulk-billing was never intended to do anything other than cover pensioners, concession card holders and low-income earners.' There is an equally important starting point not so much as the fundamental principles and fundamental public policies are concerned but so far as the Prime Minister's attitude is concerned. We all remember, when he was Leader of the Opposition in the eighties, him saying that he would take the knife to Medicare, that it was a disgrace, that bulk-billing was a rort, that he would tear it apart and that he would gut it. When he became Leader of the Opposition again in 1995-96 he recanted all that—as the questions in question time today made the point.

Why was that recanting important? That recanting was important because throughout the 1980s, under various leaders of the opposition and under various Liberal Party health spokespeople, the Liberal Party openly contemplated public policy to restrict Medicare, bulk-billing and public hospitals to people in accordance with their wealth and income. Littered throughout the history of health policy you will find examples of this. In March 1985 the then Liberal shadow health spokesperson released a paper that talked about limiting bulk-billing by doctors to patients with pensioner health benefit cards, health care cards and other concession items. In August 1995 the then opposition said it would restrict bulk-billing to pensioners and other concession card holders.

When Mr Howard became the Leader of the Opposition in 1985 people put to him all these comments and his own—where he said that Medicare had raped the country, that Medicare had been a total disaster, that Medicare was a monster, a failure, a nightmare and a disaster, that he would pull it right apart and that bulk-billing was a disgrace. In 1987 as Leader of the Opposition, when he said he would pull Medicare apart, he basically talked in terms of limiting bulk-billing to pensioners and concession card holders and having that same approach so far as our public hospitals are concerned.

That is why it was an issue when he became Leader of the Opposition again in 1995-96 and that is why, under advice from Andrew Robb and, presumably, Mark Textor or his predecessor, he recanted all of this. Why did he recant all of this? Because he knew that he could not get elected if he did not—because Medicare, after that period of time, was well established and well beloved by the Australian people. Why? Because Medicare is a sensible public policy; it is a sensible health care policy. It ensures access by all Australians to quality health care both by way of primary care that a GP can deliver and a public hospital, irrespective and independent of wealth and income. It leaves open to Australians the option of using disposable income if they like for the purchase of private health care for either primary or preventative care or for care in a private hospital.

That is why at question time, time and time again, the Leader of the Opposition and I put to the Prime Minister the things that he and his new shadow health minister at the time, Dr Wooldridge, said to the Australian people. These were commitments that he and Dr Wooldridge made in 1996, from which they have never recanted. When you go to what the Prime Minister said in February 1995—and it was littered throughout everything he said from February 1995 on—and what was said by Dr Wooldridge, and what was in their official election commitment papers for 1996, 1998 and 2001, there is always a rhetorical commitment to the universality of Medicare. There is always a rhetorical commitment to guaranteeing bulk-billing. Why? Because they know if they try and tear it up they will suffer an adverse reaction at the polls from the Australian people.

That is why John Howard says, `We support the universality of health care. Medicare should be available to everyone. Bulk-billing should be available to everyone.' But the killer quote, which made the Prime Minister most uncomfortable at question time—and we saw the shoulder twitching for the first time in a while—was Michael Wooldridge's answer to the question:

That was a prescient question because the Liberal Party had, for a decade or more, been toying with limiting bulk-billing to pensioners and concession card holders. The response was:

The Prime Minister, then the Leader of the Opposition, never moved from that position in 1995. He did not move from that position in the run-up to the 1996 election, in the run-up to the 1998 election or in the run-up to the 2001 election. There was always a rhetorical commitment.

Meanwhile, back at the ranch, what did we find so far as Medicare and bulk-billing were concerned? The Prime Minister liked saying, `The average of bulk-billing under us is better than it was under you.' Well that is terrific because we started from a base of zero. What are the facts? What is the truth? Under Labor, bulk-billing increased in every year of the Hawke-Keating Labor government to a peak of 80.6 per cent when the Howard government took office in 1996. What occurred from 1996 when the present government took office? For every year that John Howard has been Prime Minister, bulk-billing by general practitioners has gone down. It was up every year under Labor and down every year under Howard.

When the Howard government was elected in 1996 the bulk-billing rate was at 80 per cent. Did we hear the government then; did we hear the Prime Minister saying then that bulk-billing ought not to be universally available, that bulk-billing should be restricted to pensioners and low-income earners, and that the original intention of Medicare was never that bulk-billing should be universally available? No, he did not say that at all. He said, `We are absolutely committed to retaining bulk-billing.'

What have we seen over the last seven years? As I have said, every year under Howard we have seen bulk-billing go down. That is reflected where you see a dramatic decline in bulk-billing. What do we know? We know that a month after the government was re-elected in November 2001, the health minister was in receipt of advice from the health department which basically said, `Bulk-billing is about to go into free fall. We do not know where the new stable level will be. Unless you do something we cannot guarantee where the new stable level of bulk-billing will be.'

What have we seen? Since John Howard has been in office we have seen bulk-billing rates decline by 11 per cent—from a peak of 80.6 per cent, when he was elected in 1996, to 69.6 per cent in the December 2002 quarter. That is an 11 per cent drop. Over half of that drop has occurred in the last 12 months. Over half of that drop occurred during the period of time when the health minister and the government were advised that unless they took dramatic action and unless they took steps to intervene, bulk-billing would go into free fall.

At the same time, what have we seen? We have seen that Australians are finding it more difficult to find a doctor who bulk-bills. What has been the consequence when they find a doctor who does not bulk-bill? When John Howard came to office the average out-of-pocket expense for a family seeing a GP was $8.32. Now it is over $12. That is a 54 per cent increase. We have had an 11 per cent decline in the availability of bulk-billing and a 54 per cent increase in the cost for Australians.

When we look at the number of bulk-billing services we now see people not turning up to their general practitioner. For the first time since 1995-96 we have seen presentations to GPs fall below 100 million. And the 69.6 per cent bulk-billing figure is the lowest we have seen since 1989. How does the government and the Prime Minister respond to that? The Prime Minister and the government respond by reverting to type. And the AMA responds by reverting to type. After seven years of the Howard government, after seven years of attrition, stealth and grinding the Medicare rebate—and Medicare and bulk-billing—into the dust, they now see an opportunity to get back where they have always wanted to be. They have always wanted to go back to Malcom Fraser's health policy and to go back to the health policy of the Liberal Party before Medibank—let alone Medicare—where they regarded health care as a charitable disposition of public policy and by private doctors. They do not want a system which is universally available to all Australians irrespective of their income or their wealth but a system which says, `We will ensure that there is a safety net for the poor and everyone else can look after themselves—not on the basis of a clinical need but on the basis of wealth.' They want a system based not on health but on wealth.

The road they are going down—and the Prime Minister is disingenuously trying to rewrite history and pretend to the Australian community—will only mean a second-class safety net or social welfare model of health for the poor. Everyone else—Australian families under financial pressure and families with kids—will have to fend for themselves because the quality of health care that they get will be entirely dependent upon the disposable income they have and how much they can afford.

We have made this absolute commitment: you can be reliably assured that, under a Labor government, bulk-billing will be restored. The restoration of bulk-billing is absolutely our highest health priority. The Minister for Ageing can smirk, but what has always been their public policy attitude to health has been exposed: charity, not universal care. (Time expired)