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Thursday, 2 December 2004
Page: 114


Senator MARK BISHOP (4:37 PM) —The Health Insurance Amendment (100% Medicare Rebate and Other Measures) Bill 2004 brings to a temporary end a three-year saga concerning the gold card, which has been needlessly endured by the veteran community. In that time the government has failed repeatedly to fully support the gold card. Political fear just prior to the election environment jolted the government to address the problem. This bill, as it applies to the gold card, is essentially a political fix.

That observation also applies to the general Medicare policy, which this bill attempts to address. Indeed, it is amazing to consider the almighty reversal in policy from this government. We can all remember the diatribe from the current Prime Minister about abolishing Medicare. Medicare was first on the chopping block as a result of his narrow approach. There was no place for public health care in a philosophy which predominately backed a private model.

The undermining began when the government propped up the private health insurance funds with massive tax breaks for those who could afford it. The plot was to simply let Medicare die as bulk-billing diminished. Stealth was the weapon of choice to kill Medicare, and that was clearly the ideological approach. But ideology does not always work—political clout does. Australians made clear their attachment to universal health care; hence the abandonment of the ideology—certainly for the time being.

The Howard government now says it has become the champion of Medicare and bulk-billing, but this bill shows why that is not necessarily the case. There is nothing in this legislation that strengthens Medicare. There is nothing to ensure that any of the $1.7 billion will be passed on to patients. Medicare, we are told, is all the government's idea and Australians should be grateful for this enlightened policy. Total humbug, of course, but it does show the effectiveness of change in our political system.

Despite the pain of defending Medicare, we on this side are pleased to see the ALP policy for universal health care adopted. That does not mean that there is going to be any end to the skulduggery. Australians remain alert to the fact that this approach is not far below the surface. Once government revenues begin to tighten, doctors' claims for pay increases might meet a little more opposition, and the whole sorry saga of bulk-billing will return to the political agenda. Then we will see another last-minute rescue, probably immediately prior to the next election. The pattern is plain to see.

Today I would like to address the last part of the bill which provides for an increase in gold card fees. The bill increases the gold card fee from 100 per cent to 115 per cent of the schedule fee. This effectively returns the margin over Medicare previously available for GPs accepting the gold card. For the record, with the next indexation taken into account, that margin is $7.62 for level A consultations, $8.62 for level B consultations, and $12.78 for level C consultations. It should also be noted that about 78 per cent of consultations for veterans are at level B, and that rate, as I said, is $8.62.

GPs claim this is the result of more complex disabilities emerging in the veteran population. The sceptics, however, observe that publicly available research shows veterans enjoy about the same level of health as their non-veteran peers in the same age cohort. They also note that the level of consultation is wholly within the discretion of the practising GP. So there is some degree of myth about the attachment of GPs to the health care of veterans. It is probably correct to say that it is a straight commercial matter.

GPs demonstrated this when they went on strike against the Department of Veterans' Affairs early in 2003. They simply staged a walkout, saying that their fees were insufficient. They left thousands of veterans and war widows high and dry. Dentists now threaten the same successful tactic. Medical specialists embarked on this course some time ago. There is no confusion in their representations: it is about the fees or the money involved—that is, it is a straight commercial matter where veterans provide great leverage.

The most recent chapter in this saga occurred prior to the last election. The government, as part of its ad hoc decisions to save bulk-billing, introduced a new schedule of fees called MedicarePlus. This was version one, and version two quickly followed. Both versions increased payments to doctors who bulk-billed, but these changes left veterans and the gold card out of step. The MedicarePlus schedule of fees was almost the same as the gold card schedule. In some cases it was better. GPs, through the AMA, made it plain that they would charge Medicare rather than the gold card where the Medicare card had a higher fee. They no longer spoke of special respect for veterans.

Nevertheless, the gold card remains the flagship of veterans benefits in the area of health. It is at the heart of veterans health care. It is always at the centre of all arguments of those seeking changes to the status of their service. This is perfectly understandable because the gold card is free private health insurance for life, for all conditions. It is due recognition to those Australians who served overseas. It provides for those with serious disabilities from their service. It also assists widows whose partner was a veteran. It is a badge of service and, of course, it is greatly prized.

The government, through the Minister for Health and Ageing, focused only on Medicare. The government chose to ignore the veterans gold card. This, we suspect, was due to the myopia of the health bureaucracy. They have long regarded separate health systems for veterans as redundant in a world of universal health care. This is an interesting attitude and one worth exploring. The origins of health care stem from the enormous task that faced our community at the end of World War I. Many young Australians returned home badly maimed. At that time there was no basic public health system which could cope with the enormous demands. Additionally, the specific care required was often highly specialised. It centred on wound management and care for the limbless, the blind and those with ongoing serious illnesses. A network of repatriation hospitals grew from defence hospitals and continued right up until the last 10 years.

These hospitals cared for and treated veterans. They were part of the Department of Veterans' Affairs. They were considered special institutions which reflected the community commitment to dedicated care for veterans. Despite the rapid growth in public health this chain of repatriation hospitals continued as a Commonwealth responsibility. They had their own special ethos and were commonly regarded by veterans as `ours'. Veterans rightly have always regarded their service to the nation as not only different but unique. These institutions, as part of the Department of Veterans' Affairs, were a public demonstration of their commitment to that service.

But it became increasingly obvious that centralised health services were no longer the most convenient or efficient model. As well, publicly managed institutions went out of favour as governments sought to outsource or devolve service delivery downwards. Alternative sources of state public and private health care were available and they continued to grow. In many cases these alternatives were just as suitable and were located far more conveniently. Despite initial misgivings the sale and transfer of the repatriation hospital network has been a success—it has been the best of both worlds. Former repatriation hospitals retained their specialised care and priority for veterans but their monopoly was largely removed. For partners and families this was of great value as travel in our cities can be quite difficult, particularly for our ageing World War II generation.

Along with this, the electronic card system developed. This streamlined management and facilitated more diverse provision of care. Rationalisation of these cards, which denoted different levels of entitlement for health care, also took place from time to time as part of government policy changes. From this emerged the gold card, which was given firstly to ex-prisoners of war and the totally and permanently incapacitated. War widows then became eligible, and then its use was extended to those with severe disabilities who also received some part of the service pension. In more recent times we have seen eligibility extended to all those who are over 70 years with qualifying service. It has also been made available to ADF personnel seriously disabled from their service. Thus a limited and, in some senses, declining group of veterans became a much larger group—particularly in the last three to five years, when the numbers have increased by almost 300 per cent. For the AMA and GPs this became a Trojan horse. The population for which they had done a special deal suddenly doubled and in some cases tripled. It is no surprise therefore that their attitude became less accommodating and less charitable.

The range of health services attached to the gold card is almost limitless. So it should be of no surprise that veterans health care is a major business. The total budget this year, for example, is almost $4.4 billion. Of this, over $700 million is paid to medical practitioners, and $1.67 billion is paid to public and private hospitals. A further $520 million is paid for other health care. Aged residential care costs $770 million and DVA administration takes another $110 million. In anybody's terms, these are massive amounts of public money. It simply illustrates the huge cost of military service over and above the direct defence effort required at the time of engagement. This could be called the downstream cost of war. Unfortunately, it is not something ever considered when costs are estimated at the time of engagement. An even greater cost is compensation, which this year will be $2.8 billion—not including service age pensions. This represents human loss, either through disabilities or through loss of a husband or a parent.

So veterans health is big business. But it is not a business that is well known or understood. In considering it we must be aware of its origins. We must be aware of its very special nature within our current system. It is built on the public commitment to care for those who serve our nation's defence. It is historic but remains absolutely relevant in terms of its tradition and commitment to generations who might go to war in the future. That is why the gold card has become such a sensitive issue in recent years. That is why the government panicked in its election commitment to increase GP fees to 115 per cent. And that is why the Howard government is still in trouble with respect to specialists. Veterans are now very seriously inconvenienced by lack of access to specialist care. For the specialists it is a straight commercial matter. They get more revenue from Medicare and private health funds. They say they treat veterans and widows below cost, and that stretches too far their commitment to the care of the veteran population.

In Tasmania, as all veterans there know, specialist care is simply inordinately difficult to obtain. Orthopaedic care, I am advised, is available only as a public patient, which means joining the waiting list. Access to specialists in Tasmania has always been difficult—predominately due to the size of the population—but now commercial reality has made it even more difficult. If the government wants to honour the gold card in that state, it has no option but to pay up.

So far all that has been offered is that from 1 January next year the fees will increase by 15 per cent for consultations and 20 per cent for procedures. Whether that will be sufficient is, of course, at this stage unknown, but the feedback my office and I are receiving from the AMA and interested parties in Tasmania is that it will not be. Specialists' relations with DVA are poor, and they have made the point repeatedly that other business is now more commercially attractive.

I am therefore pessimistic about future prospects. But worse, veterans will continue to suffer. The gold card in Tasmania is, at least, devalued currency, and veterans feel let down. They believe the public commitments to them are not being honoured. As expressed by my colleagues, the opposition support the bill but, as far as the veterans gold card is concerned, we note that this saga will continue.