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Wednesday, 28 May 2003
Page: 15167


Ms KING (11:57 AM) —It is great to hear the member for Canning, sensitive new age man that he is, giving sympathy to women with children and the difficulties they have in accessing Medicare offices. What he failed to acknowledge is that the woman he is speaking about will probably be paying far more to access a general practitioner under this government's proposals than she is currently. If you ask women with small children what they are more worried about, driving to the Medicare office or paying more from the already tight family budget for general practitioner services, I can tell you where their concerns lie: their concerns are with this government's proposal to undermine Medicare, not whether they are going to have trouble driving to a Medicare office. The member for Canning may want to talk to some of those women in his electorate about what this government's proposals are really going to do.

I would like to turn my attention to the specific aspects of the Health Care (Appropriation) Amendment Bill 2003, which extends the period of operation of the Health Care (Appropriation) Act 1998 to allow the Commonwealth to enter into the next round of Australian health care agreements with the states and territories. The Australian health care agreements, which are negotiated bilaterally with each state and territory, essentially provide Commonwealth moneys to the states in exchange for ensuring the states continue to provide free hospital care. Over the past 15 years, the Commonwealth, states and territories have negotiated these health care agreements, and new agreements are about to be negotiated for the next five years.

The principles upon which the Australian health care agreements are based are enshrined in legislation. They are: that public hospital services must be provided free of charge to public patients; that access to these services must be on the basis of clinical need and within a clinically appropriate period; and that people should have equitable access to public hospital services, regardless of their geographical location. Those are principles that, in my view, are being broken by this government as it attempts to Americanise our health system. Specifically, the reduction in funding to public hospitals, which the level of funds appropriated by this bill represents, has the potential to undermine the hard work that has been done over the past few years to restore our public hospital system.

In Victoria, the Kennett government did enormous damage to our public hospital system with its overly zealous pursuit of cost cutting to social and health services. Even the head of its own Department of Human Services admitted that they got it wrong. Grudgingly, he said, `We cut too much from public hospitals.' The damage is only just beginning to be repaired. But this year's budget shows that the Howard government has no interest in saving public hospitals. It has no interest in restoring public hospital systems to the levels at which they once were. It has no interest in working with state governments to actually improve public hospitals.

This year's budget shows that the Howard government is withdrawing funding for public hospitals in the forward estimates. The member for Canning wondered where we got those figures from. We got those figures from the government's budget papers. The emergency departments at our public hospitals are already under greater pressure because the Howard government has let bulk-billing run down by more than 12 per cent over the seven years it has been in government. Instead of recognising the pressure that the public hospital emergency departments are under, the Howard government is withdrawing a further $918 million over four years from our public hospitals.

In April, the Commonwealth Chief Medical Officer, Richard Smallwood, was reported in the Age as having told a health conference in London that Australia's public hospitals were `in varying degrees of dilapidation' and that morale amongst doctors and nurses was fragile. He was quoted as saying:

The results of our care and patient experiences of the health care system are too often less than ideal ... Our public health care systems never seem to have enough resources ... Access to care, while universal, is too often delayed. The medical workforce is undermanned, maldistributed, or both, and the shortage of nurses verges on the calamitous. In both professions, morale is fragile.

What is the Commonwealth's response to this? What is the Commonwealth's response to its obligations to make sure that we have universal access to public hospitals? It is to withdraw a further $918 million over four years from that very system. The withdrawal of $918 million in Commonwealth contributions from public hospitals means that fewer nurses will be able to be employed within that system, fewer operations will be undertaken and there will be longer waiting lists for elective surgery. This cut to public hospital funding precisely offsets the budgetary impact of the government's $917 million Medicare package, which fundamentally changes the Medicare system, puts an end to bulk-billing for Australian families, places public hospital emergency systems under pressure and undermines the universality of health care in this country. Whichever way you look at it, this government seems to think that there should be one system for those that it likes to view as the `deserving poor' and another for those that it thinks can afford to pay.

At the same time as attacking Medicare, the Howard government is attacking our public hospitals. The government's proposed changes to Medicare cannot be separated out from the Australian health care agreements. The state health ministers have jointly issued a communique which outlines their concerns. The ministers said any discussion about funding for public hospitals could not be separated from the Commonwealth's planned overhaul of Medicare. They said:

The Prime Minister's plans for Medicare will cost families more and push those who can't afford to pay into public hospital emergency departments.

State and territory ministers detailed to the Commonwealth health minister the key principles they believe should underpin the Australian health care agreements. They included maintaining and developing Australia's health care system based on the Medicare principles of universality, equity and access; maintaining and developing the key components of Australia's health care system, including Medicare, sustainable public hospital related services, the Pharmaceutical Benefits Scheme, aged care services and the public health system in general; and recognising that the policy decisions of the Commonwealth do not exist in a vacuum and can have serious consequences for state and territory based health services. Key areas that the ministers believe need to be addressed by the Commonwealth include not only the decline in bulk-billing and its impact on emergency departments but also the chronic underfunding by Canberra of nursing home places. They went on to say:

Clearly, this offer—

that is, the offer by the Commonwealth—

does not recognise that the Commonwealth's planned changes to Medicare have the potential to place the States and Territories under even more financial pressure.

The Commonwealth health minister said that the government's Medicare changes were for all Australians. It is a reminder of the 1996 election, when the Prime Minister had as his slogan `For all of us'. Over the course of this government we have learnt that what the Prime Minister is really saying is, `I'm only for some of us.' These changes to Medicare can mean only one thing: a two-tiered, user-pays health system under which Australian families will pay more for doctor visits. Doctors will be given financial incentives to bulk-bill concession card holders, which is in fact a de facto means test, but they will be given the green light to charge higher fees for everyone else. Australian families with two kids who earn more than $32,300 a year are not eligible for a concession card. For them, bulk-billing will end and, when they visit their GP, bit by bit they will be asked to pay more.

The member for Parramatta said last week that this was a good thing. The people who expect governments to provide money for services make him want to throw up—they were his words. What an extraordinary attitude! Most people in my electorate do not expect something for nothing. They work hard; they pay taxes. They believe that they have a contract with this government through their Medicare levy for the provision of a free public hospital service and for access to bulk-billing doctors, no matter how much they earn and no matter where they live, whether it be in the town of Ballarat in my electorate or in the rural town of Halls Gap, where there is no access to bulk-billing doctors.

In my electorate bulk-billing has dropped to around 53 per cent, and it is dropping daily. The average family income is $33,000 a year. It is half that of the income in the Prime Minister's electorate of Bennelong, yet the bulk-billing rates in his electorate are around 80 per cent. This government seems to have no understanding of what people are actually experiencing. People expect their government representatives to understand what their lives are like. They expect their elected representatives to understand the financial pressures that they are under and put in place policies that reflect those.

This government has broken the contract it has with the Australian people through the Medicare levy by withdrawing funding for public hospitals, as represented in this bill, and giving up on bulk-billing. This government taxes more and more and yet spends less and less on services and withdraws from those services continuously.

The fundamental principle underlying Medicare is that health services should be available according to medical need, not a patient's capacity to pay. The Australian health care agreements are interlinked with universal access to bulk-billing. A decline in GP services means more people accessing emergency services in public hospitals. If Medicare is to be preserved and bulk-billing restored, Australians need a government that is committed to Medicare and to bulk-billing.

When Labor was last in power, bulk-billing by general practitioners was at a high of more than 80 per cent, and there is no reason why we cannot get back to that. Every year since the election of this government has seen a decline in bulk-billing rates; a decline of over 12 per cent since its election. Announced in the Leader of the Opposition's budget reply is a plan to save Medicare with a $1.9 billion package to reverse the collapse in bulk-billing by lifting the patient rebate for bulk-billing for all Australians, no matter where they live and how much they earn. It is a good policy, and it is one that is seen by the AMA as being a better policy than the one the government has on the table. It includes a proposal to immediately lift the Medicare rebate for all bulk-billed consultations to 95 per cent of the scheduled fee, an average increase of $3.35 per consultation, and to subsequently to lift the Medicare patient rebate for all bulk-billed consultations to 100 per cent of the scheduled fee, an average increase of $5 per consultation. In addition, we will offer financial incentives to doctors to extend bulk-billing, especially in regional areas such as my electorate of Ballarat where the collapse of bulk-billing has been extremely noticeable. Doctors in outer metropolitan areas and major regional centres will receive an additional $15,000 each year for bulk-billing 75 per cent or more of their patients. Doctors in rural and regional areas will receive an additional $22,500 each year for bulk-billing 70 per cent or more of their patients.

Lifting the patient rebate and introducing financial incentives to bulk-bill will help to stem the current dramatic decline in bulk-billing and act to make bulk-billing available to more Australian families. There is nothing in the government's Medicare reforms that will restore bulk-billing. Bulk-billing rose every year under Labor and has fallen every year under the Howard government. The decline in bulk-billing is denying families access to affordable health care, forcing them to pay more and more to see a doctor, despite the fact that Australians have paid for Medicare through their taxes for nearly 20 years. Under this Prime Minister, bulk-billing by GPs has declined in my electorate by more than 10 per cent, from a high of around 75 per cent to less than 53 per cent today.

When I asked the Minister for Transport and Regional Services during question time last week whether he was concerned about the decline of bulk-billing in electorates such as mine, he said he would rather talk about something more interesting. The minister may not be interested in the decline in bulk-billing in regional areas, but families in my electorate certainly are. They know that it is now more expensive to access a doctor and they know that something has to be done to increase the number of doctors who bulk-bill. They know that something has to be done to increase the number of doctors in my electorate as well. The minister may not be interested in the decline of bulk-billing in my electorate, but families under pressure certainly are. By offering GPs a significant increase in the Medicare rebate and powerful financial incentives to meet bulk-billing targets, Labor will restore bulk-billing to a better level. These measures are the first step towards Labor's objective to restore the average national rate of bulk-billing to 80 per cent—or more.

In the few remaining minutes that I have, I want to talk particularly about the Australian health care agreements as a policy document versus a funding agreement. One of the most disappointing aspects of the Commonwealth's decision to cut $918 million from public hospitals is that it undermines the potential of the Australian health care agreements. I co-authored a paper with Dr Vivian Lin about our experiences of negotiating the first round of public health outcome funding agreements with all states and territories. One of the biggest challenges was how, in the context of negotiating a funding agreement, you also jointly commit to policy reform. We managed to do that in public health because, firstly, we negotiated the funding separately and we were upfront about funding commitments that had been made and were determined to work to keep them—something that has been undermined in this agreement—and, secondly, we separated our agreement on policy through a separate memorandum of understanding and resourced it through a national public health partnership.

The Australian health care agreements, like the public health outcome funding agreements, are much more than just a transfer of money between the Commonwealth and the states. They have the potential to underpin an entire Australian health care policy, something that we do not currently have in this country. Much was anticipated from this round of negotiations. Many clinicians certainly had the hope that this round of negotiations would see a broader commitment to a national health care policy. The early discussions between the Commonwealth, state and territory ministers saw agreement that this round of Australian health care agreements should incorporate national objectives for the provision of improved care for all Australians. Michael Reid in the Australian Medical Journal argued:

... ACHAs will need to extend beyond public hospital issues to incorporate primary care. There will need to be discussion in the agreements on primary care, chronic care, mental health, Indigenous health, aged care, rural health, public health and, presumably, agreed quantifiable measures to assess achievement of these national objectives, while maintaining flexibility of resource allocation.

I note that the Audit Office has been fairly critical of the department in terms of its performance indicators and its development of performance information in the Australian health care agreements. I certainly hope that extensive work is under way to improve that system; certainly within public health we undertook quite an extensive process to do so. The dollar amount that would be required would be quite small compared to the amount within the Australian health care agreements. What is happening with the Australian health care agreement negotiations is that the Commonwealth's offer, being $918 million less than anticipated in its own forward estimates, means that any hope of getting the sort of policy reform that was anticipated from this round has gone. Other areas—such as mental health, which is chronically underfunded—are also under pressure. I say to the public servants in the chamber today: I do not envy you at all. I think that you have been handed a poisoned chalice on this one.

If the last round of negotiations was any guide, the next agreement will be devoid of national health policy, contain poor performance indicators, be largely incomprehensible to anyone else but its authors and preserve the existing capacity and incentives to shift costs between the states and the Commonwealth, and vice versa. It will again represent a missed opportunity in this country. By presenting the states and territories with an ultimatum that represents a cut of almost $1 billion to public hospitals at the same time as pursuing a two-tiered system of access to bulk-billing by general practitioners, this government has undermined any goodwill that exists to get any real reform in health care. It is a missed opportunity. Whilst I wish the public servants well in their negotiations with the states and territories, I certainly think the government has undermined their capacity to negotiate good, solid health policy reform by cutting $918 million out of this round of the Australian health care agreements.