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Community Affairs Legislation Committee
16/05/2014

STANKEVICIUS, Mr Adam, Chief Executive Officer, Consumers Health Forum of Australia

STEPHENSON, Ms Donna, Policy Director, Consumers Health Forum of Australia

Committee met at 09:29

CHAIR ( Senator Boyce ): Welcome. I declare open the inquiry of the Senate Community Affairs Legislation Committee into the Health Insurance Amendment (Extended Medicare Safety Net) Bill 2014. I have a statement as usual that I need to read out.

Committee proceedings are protected by parliamentary privilege. It is unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee, and such action may be treated by the Senate as a contempt. It is also a contempt to give false or misleading evidence to a committee.

The committee prefers all evidence to be given in public, but under the Senate's resolutions, witnesses have the right to request to be heard in private session. It is important that witnesses give the committee notice if they intend to ask to give evidence in camera. If you are a witness today and you intend to request to give evidence in camera, please bring this to the attention of secretariat staff as soon as possible.

If a witness objects to answering a question, the witness should state the ground upon which the objection is taken, and the committee will determine whether it will insist on an answer, having regard to the ground which is claimed. If the committee determines to insist on an answer, a witness may request that the answer be given in camera. Such a request may, of course, also be made at any other time.

We have a short program today so, in order to allow adequate time for questioning of witnesses, I would like to suggest that witnesses keep their opening statements brief and no more than five minutes per individual or organisation.

You have lodged submission No. 3 with the committee. Do you wish to make any amendments or alterations to that submission?

Mr Stankevicius : No.

CHAIR: I now invite you to make a short opening statement at the conclusion of which I will invite members of the committee to ask questions.

Mr Stankevicius : Thank you. The introduction statement has certainly got a lot longer than the last time I was here.

CHAIR: I understand it is yet to get longer. It is a sort of protective device, and you always feel a bit concerned that, if you leave something out, that might be the bit that matters.

Mr Stankevicius : Indeed. Thank you very much, Senators, for the opportunity to appear before you today. The Consumers Health Forum of Australia is the national peak body representing the interests of healthcare consumers. We work to achieve safe, quality, timely health care for all Australians supported by accessible health information and systems.

It is important to put any debate on healthcare financing, including the Medicare safety net, into context. We have been highlighting for a long time that health consumers, particularly the chronically ill in this country, are already taking personal responsibility for their health care through the payment of extraordinarily high out-of-pocket costs.

We know that Australians already make substantial direct contribution to healthcare costs. Our research has shown that individual co-payments in Australia, consumer co-payments, comprise 17 per cent of total healthcare expenditure in Australia—higher than most other OECD countries, including France and the UK.

Individual consumer co-payments, so out-of-pocket payments by consumers, are the largest non-government source of funding for health goods and services in Australia. On average Australians are now spending more than $1,000 a year in out-of-pocket health costs. By international standards, the average rate of out-of-pocket costs that we pay is amongst the highest in the world.

Unfortunately, Australia is an increasingly difficult place to live for those people who are chronically ill, who have rare diseases, and they are experiencing very high out-of-pocket costs. These health costs can run into many thousands of dollars a year and are not always covered by Medicare and not always able to be covered by private health insurance. Thankfully, many of us will never have to experience this, but those with chronic illness and rare diseases certainly do.

We have collected hundreds of stories and some of them you will see in the analysis of our consumer survey that we provided to you earlier, and that information is also on our website. What we found from those consumer stories is that consumers are having to make really tough decisions. They are delaying visiting medical services, even when they believe those services are needed.

We are seeing an increasing number of people who can afford to see a GP or get their prescription filled but not do both, and the proposal for increased consumer co-payments will make those choices much more difficult.

You will have seen in the media over the past few weeks, but we also saw it in our survey, consumers or parents who are having to choose between managing their own healthcare needs effectively and managing the healthcare needs of their children. We are also seeing an increasing level of stress and anxiety from consumers in the difficult choices that they are having to make—those choices between other essential factors of life or expenditure items such as food, education for their children and health care. Increasingly, they are getting very stressed in having to make those difficult choices.

One factor that we do not often consider is that, unfortunately, people are self-prioritising their healthcare needs. Many of them, without medical qualifications, are having to decide—'I can't afford to go and see the doctor, so will I go and see a community nurse? Will I go and see the pharmacy? Will I sit in an emergency department and wait for care even though I am not the one who is best able to make those decisions?' Again, increased co-payments will make those decisions more difficult for people.

In recognition of some of these high costs in the past, governments have introduced safety nets, and that is obviously the discussion that we are having today about the extended Medicare safety net. They offer some protection against these out-of-pocket costs. As senators would be aware, in the 2013-14 budget, the government introduced a measure to raise the extended Medicare safety net upper threshold to $2,000. It also introduced a measure to phase out another protection against high out-of-pocket costs called the net Medicare expenses tax offset. Under this scheme, once the threshold has been reached, people can claim a tax offset for a broad range of services and products, not just out-of-hospital services as under the EMSN. Obviously, we have heard in the 2014-15 budget that there will be further changes that will reduce patient affordability, particularly for those with chronic conditions and rare diseases, and will bring with them much higher health costs.

We acknowledge that the current system—and you will see it in the Empty pockets research that we also shared with you today—of co-payments and safety nets is inadequate. One of the highlights of the research report is that we do not actually have a national policy on co-payments and how they are applied. Certainly, we are seeing increasing inconsistency between the safety nets in the PBS space and the MBS space, and there is a question about whether there should be some better alignment between the medical services that we are subsidising after a particular threshold and the pharmaceuticals that we are subsidising after a particular threshold. They are certainly not aligned at the moment and there is some work that we could be doing to improve that as well so that consumers are not hit, particularly, again, those who are chronically ill.

I suppose what the research demonstrates is that one of the significant flaws of the current safety net is that it tends to advantage those people who have acute, one-off, short time frame illnesses as compared to those who have lifelong or later life, long-term illnesses. Obviously, in a financial year or in a 12-month period, if you have those high-cost, acute, short time frame illnesses, you can get it in the 12 months, you have reached the threshold quickly and those costs are reduced for the rest of that financial year. If you have a chronic condition spread over 10 years or 20 years, you may never reach the threshold. Particularly if it goes up to $2,000, you may sit underneath that threshold and not actually be able, because of the nature of your illness, to get there, but you still experience those significant costs.

One of the things that we do not often consider is that people with chronic illnesses and rare diseases, again, are not always those with concession cards. I was talking to Rare Voices people yesterday and they were indicating that there are 1.2 million people in Australia with rare diseases, and they cover the spectrum. It can be people on low incomes, but it will not necessarily be people who have concession cards. They are still struggling in meeting those chronic need costs in terms of managing their health care and we cannot always assume that they will be getting the benefit of those concessional arrangements that are in place. So there are high users of the system who are not necessarily concessional users of the system.

There is also a question, I suppose, in the research for us, and I think in the other submissions that have been brought to the committee's attention, about whether there is a particular class of medical specialist who might be gaming the current safety net system.

Senator MOORE: Come on, name them! The evidence is there.

Mr Stankevicius : Exactly. I think the evidence points to it, particularly in obstetrics and IVF. Unfortunately, it seems to be costed quite strongly in the women's health area whereby doctors are essentially charging exorbitant fees on the basis that they can say to the consumer, 'You won't be covering it because, again, it is within a 12-month period. You will get to the threshold and the government will cover the rest.' They are gaming the system in a way which increases their remuneration and obviously increases the cost to government but, fortunately, in this instance does not necessarily increase the cost consumers—or at least not exorbitantly, anyway. There are still quite shocking costs in those areas in particular, but the research absolutely does suggest that there is a question there about the way in which the system is being managed or gamed by medical specialists.

I suppose the other thing that our research sees is that the out-of-pocket costs in the healthcare sector that are being experienced by consumers are not just about medical services. Aids and appliances are certainly very high on the list. Things like oxygen tanks, walking frames and those types of aids to assist people to live their daily lives, particularly people with chronic illness, are not often covered under the subsidy schemes that we have at the moment and are not necessarily covered by the Medicare safety net. They are things that are outside the current system and will not contribute to reaching the threshold but still cost consumers a lot of money out of their own pockets.

Until we have the full picture through the upcoming Senate inquiry into out-of-pocket costs in health care it is very difficult for us to make a succinct or very clear judgement or to establish a clear position on where the safety nets best sit across both medical benefits and pharmaceutical benefits. We would encourage the committee, until the report on that out-of-pocket costs inquiry, to reserve its judgement on where best to put the Medicare safety net threshold.

CHAIR: You have given us two documents which we will take into evidence called Health consumer out-of-pockets costs survey: results and analysis May 2014 and Empty pockets: why co-payments are not the solution March 2014.

Senator MOORE: Good morning and congratulations on your appointment.

Mr Stankevicius : Thank you very much.

Senator MOORE: Is this is your first time before us?

Mr Stankevicius : Absolutely.

Senator MOORE: Congratulations.

Mr Stankevicius : This is my 12th week in the job.

CHAIR: We will be expecting some in-depth responses!

Senator MOORE: We always acknowledge the work that your organisation does. You are a regular contributor to these committees, so thank you very much. I also share the concern about the fact that we have not had the references committee look at this whole issue, because there is so much going on, before looking at this piece of legislation. But in terms of this piece of legislation, I have always wanted to know exactly what is in and what is out. What can you claim as out-of-pocket expenses? We have the department coming later in the morning, but unfortunately we do not have a submission from them. I had been hoping that would be defined in there. I am sure it is on their website somewhere. But just in terms of the way the system operates, as you pointed out in your submission and also in the really useful Empty pockets document, there is a lot of confusion among people about what they can claim and what they cannot. You mentioned support aids and so on. From your understanding, what exactly makes you get to the threshold point? What constitutes out of pocket?

Ms Stephenson : At the moment, we have a threshold. It is 80 per cent after the Medicare gap rebate. It is not the full amount; it is 80 per cent. There is a limit. We talked about gaming and how high specialists can set their prices. They limit that to 300 per cent of the Medicare rebate. So if it is at $500 and someone charges $3,000, they will quickly get to the Medicare threshold. If it is $500, the limit is $1,500.

CHAIR: By '300 per cent' you mean three times?

Ms Stephenson : Yes, three times the Medicare fee. That is at the moment, and just for services that are provided through the MBS. Services that are not included are in-hospital costs, private costs for people if they go to hospital and they do not go public. If they need physiotherapy, for their chests, or in rehabilitation, then those costs are not included in that.

Senator MOORE: So it has to be directly health related, to a condition.

Ms Stephenson : Yes.

Senator MOORE: And there are exclusions as well. So that is how it operates. I have a few questions. One is to do with the issue you raised about how the way that the system operates allows people, quite legally, to manipulate the system and set their fees accordingly. There is no doubt that that happens. The figures that you have provided indicate that it is quite a significant practice. From Empty Pockets,the information you have indicates that that is quite a significant process. In your opinion, is that just good business—that people have seen a system and worked it well?

Mr Stankevicius : I think that people will use the opportunities available in a system, in a commercial sense, to build their businesses and to develop them. I am not saying that that is necessarily heartless—

Senator MOORE: No, but it is a fact.

Mr Stankevicius : Yes, it is a fact, absolutely.

Senator MOORE: And in terms of high-cost specialist activities.

Mr Stankevicius : Yes, absolutely.

Senator MOORE: As an organisation and in the community generally, do you have any idea of the background between $1,200, as it is now, and $2,000? Is there any science in those figures that you are aware of?

Mr Stankevicius : We are not aware of any modelling. As we mentioned, with the 2014-15 collapsing of the extended Medicare safety net and the Medicare safety net into a simplified Medicare safety net, it goes back down to $1,000 and a more reasonable level—is it $400 or $600?—for singles.

Ms Stephenson : I think it is $700.

Mr Stankevicius : So it does go back down again, but again there are exclusions and carve-outs for the proposed new safety net. This one is proposed to come in on 1 January 2015. The one announced in the 2014-15 budget would come in on 1 January 2016 and bring it back down to $1,000. The carve-outs and the exclusions get more technical and more difficult to work through. The capping also gets more difficult to work through. It is not a simple matter of being just as easy as it is now to reach the threshold. With a new lower threshold, it will still be more difficult. Consumer confusion is one of the questions when you start carving stuff out, excluding it, putting caps on it and only having certain percentages that apply. You cannot necessarily plan your healthcare expenditure to get to the threshold, particularly if you are making decisions across financial years and you want to be able to ensure that you do get some kind of compensation. As I said, if you have got a chronic illness and you are trying to manage that across the years, it makes it more difficult.

Senator MOORE: Does your organisation have any information yet about what the overall impact is going to be on the series of legislation changes that we have received? You have just mentioned the one that is going to have the new threshold and also the new co-payment that has been announced in this budget. Has anyone got their heads around how all of it is going to work together?

Mr Stankevicius : Not how it is going to work together yet, no. I think that would be some significant modelling. Again, you can probably ask the department about that.

Senator MOORE: Yes. I can't wait!

Mr Stankevicius : They have obviously had longer than we have had to think about it. The Empty Pockets report looks at the co-payment issue quite comprehensively. It has those findings. I think the government's original speculation as to why a co-payment would be introduced, particularly for Medicare services, has changed. Originally it was about sending those price signals to consumers. Now it is much more about the medical research future fund and investing for the future. Our research suggests that the original objectives that the government was outlining, about sending price signals and reducing demand and reducing overall costs, would not actually come to fruition, on the basis of the international research. The one in particular is the RAND Corporation study, which people keep telling me is hardly a leftie institution, so it is not as though they have got consumers at the front of their mind, but they do very rigorous and solid research, and they are the ones that are strongest—and I think the most longitudinal research too. They have come up that it is not going to make long-term savings to the healthcare system. But I suppose the way in which the new simplified Medicare safety net, as proposed by the government, interacts with co-payments is not something we have actually seen yet. But is it the new one that will exclude co-payments from the threshold?

Ms Stephenson : Yes. So the $7 co-payment will be excluded from that threshold.

Senator MOORE: It is an obvious question, isn't it?

Ms Stephenson : You pay this, but it will not be included.

Senator MOORE: This is the simple one and the other one is going to be the new, simplified one. This one comes first—the one in front of us today?

Mr Stankevicius : Yes, this will come first if the Senate passes it.

Senator MOORE: So this one kicks in in July, and then the new simplified one is going to come in—

Mr Stankevicius : On 1 January 2016.

Senator MOORE: six months later.

Mr Stankevicius : Yes.

Senator MOORE: And that will have a different rate across the board.

Mr Stankevicius : And different exclusions. This is probably one of the questions that should be on senators' minds. If we are having between 12 and 18 months of one threshold with a certain set of exclusions and then a change next January, not even with a new financial year, it is going to be very confusing for consumers and industry to be applying new thresholds.

Senator MOORE: And senators.

Mr Stankevicius : And senators. For the system generally, I would suggest.

Senator MOORE: You have read other submissions, I know, because that is what you do. The National Seniors Australia have quoted your research as well, because I know you work closely together. They are concerned about the fact that there is still no difference between a family rate and a single person's rate. Is that something that has come up in your research?

Mr Stankevicius : The difficulties families and individuals face on a whole range of levels come out through our research. I think one of the things I mentioned was that juggling parents and children's health care is very difficult. We know in life in general that if you do not have that familial, pastoral support in addition, either as part of a family arrangement or as part of a close friendship, it makes managing your health care much more difficult, particularly if you have a chronic illness. It is those general supports, helping you get to the shopping, helping you do daily tasks which, if you were by yourself, you would otherwise find difficult. If you do not have those familial supports, it is much more difficult.

Senator PERIS: In your report you have expressed concern for consumers with poor health and with high-level needs, for whom the extended Medicare safety net is a key support mechanism. In your view, how many of these consumers might there be and what type of health issues and high-level needs might be encompassed by this concern?

Mr Stankevicius : I am not sure we can actually put a number on that. I think I gave you an example of one class—the rare diseases space in Australia has 1.2 million consumers. There are a significant number of consumers experiencing chronic illness. Some of that is debilitating; some of it is manageable. They will obviously be the highest end users who are likely to reach the threshold quicker. But I think the 2009 research—and there is probably a question for the department about whether they have updated that 2009 research—suggests there is a class of other high-cost expenses that might be applied to a more affluent set of consumers who are also using the safety net to pay for those high-end procedures.

Senator PERIS: Is there any jurisdiction that flashes the red light more than other jurisdictions? I know in the Northern Territory we have a very high rate of chronic diseases.

Mr Stankevicius : I think the positive side of health care in the Northern Territory is the fantastic work the AMS is doing. It is not always as obvious as it is in the general healthcare sector and the Medicare system, because the AMSs operate on a different funding model and interact with Medicare in a different way. They provide much more holistic services. Yes, I agree there is a higher rate in the Northern Territory, but I think the community based or community controlled response means that it is managed a bit differently.

It is really interesting that one of the things we saw in the research report from the Australian survey that we did on co-payments was that there was about a 15 per cent difference in responses to the question: 'I have the capacity to buy the healthcare services that I need.' There was a 15 per cent difference between metro and regional Australia. It was about 15 per cent lower in regional Australia. So they were the ones who were feeling they could not buy the healthcare services that they needed.

That survey was—

CHAIR: Is this a comment on availability as well, do you think?

Mr Stankevicius : It was a market research survey, so I am not quite sure how deep they went into it. But it was an eastern seaboard survey, so it was mainly focused in Queensland, New South Wales and Victoria, unfortunately. All the other research in the survey on private health insurance and co-payments and their impacts was all pretty consistent across metropolitan and regional areas. It was the 'I can pay for the health services that I need,' question where the disparity really came out.

Ms Stephenson : There are also jurisdictional differences in people's travel costs when getting to services across our vast states and territories.

CHAIR: You are talking to the committee that did an inquiry into impacts.

Ms Stephenson : So they cannot get to their specialist, support for patients' transport is being removed and therefore they are not accessing care, because they cannot afford the transport let alone the additional cost to seek that treatment. They are also very important costs.

Mr Stankevicius : Certainly, the PAT scheme is an issue that is being raised more and more through consumers. Interestingly, I think metropolitan consumers may be feeling a bit left out. So they are indicating now that in a lot of the cities the hospitals are actually making a bit of money through their car parks. So, $40 per day for car parking for people, either as consumers, carers or family members, is adding to the cost when they have to travel 500 kilometres as well.

CHAIR: In the majority of cases, those car parks would be managed by external companies anyway.

Mr Stankevicius : Exactly, contracted out.

CHAIR: I want to tease out one issue a little bit further. I am assuming that the comments you make around the different effects of the safety net for those with acute illnesses and those with chronic illness are because you have the opportunity to recover financially if it is an acute illness; whereas if it is chronic then your costs are simply ongoing. Is that correct, and could you perhaps talk a little bit more about that?

Mr Stankevicius : If you have an acute short-term incidence procedure or illness then you are going to have a very focused period of maybe one or two months of being at the hospital, seeing specialists, having diagnostics and pathology, going back to the GP and taking all kinds of drugs. The costs accumulate very quickly, and you will hit the threshold relatively quickly. If you have a chronic illness, it will be those regular costs. Unless you have a spike in the illness, you will not necessarily have a hospital visit or have a particularly intensive experience that requires a lot of practitioners to be seeing you and charging you.

CHAIR: So, you might not reach the safety net, although you have significant ongoing health costs.

Mr Stankevicius : Exactly So, it is the way in which it is managed and the line in which it is managed. In the out-of-pocket report, there is a great example on page 20 of managing hepatitis C and the difference between managing the acute and chronic costs. Because the safety net is based on, I think, a calendar year period, it depends on how it is managed over the 12 months, so you can reach it pretty quickly. If that happens in the first few months of the year, then you obviously have a benefit for the rest of the 12-month period.

CHAIR: So try not to get sick over December-January—is that what you are saying?

Mr Stankevicius : Exactly.

Senator MOORE: One of the elements in this particular bill takes away the requirement for Medicare to send a written notice to tell you that you are getting close to the limit. That is just in there and it is not mentioned anywhere in your submission. Is that something that anyone cares about?

Mr Stankevicius : I think it is how you define written notice. From my understanding of this system, there are opportunities for them to email. I am not sure whether that is considered a written notice or not.

Senator MOORE: We will have to ask the department.

Mr Stankevicius : I certainly know that with the introduction of myGov and the translation of all the Medicare data over to that system, that there will be regular signals, probably text messages as well as emails, in terms of notification. My personal experience of going to the doctor is of the last three or four times I have been over the past year, so it has been interspersed.

Senator MOORE: Not 11 times?

Mr Stankevicius : No. MBS online has been down almost every time I have gone there. In terms of the efficiency of that system, there are obviously questions about the way in which it keeps up with the threshold. Certainly, it is one of the questions we have asked in terms of the proposed co-payments. If you are having concessional card payments based on 10 visits and Medicare, not the doctor or their staff, are going to be keeping a record of those 10 visits, when the system is down will that person have to pay and then be refunded? How will the co-payment actually work when the network is down, as it so often appears to be? Again, maybe that is just me and my GP—

Senator SMITH: Let us take it as a given that government is trying to seek savings from the extended Medicare safety net arrangements. Is it a better policy solution to raise the threshold in the upper threshold category or would it have been a better policy solution to raise both thresholds? What would be a fairer outcome? Preserve the current arrangement as it relates to concessional card holders at the moment, so it is not for them to incur any additional expenses? Is it fairer to partition that group of people or is it fairer to spread it over both thresholds?

Mr Stankevicius : I think it is always a policy choice for government. It is a policy choice about the things that it is trying to incentivise. We were having a discussion about this over the past few days. If the system is being gamed by high-cost practitioners, particularly in the assisted reproductive end, governments are by and large encouraging of people who want to have children. It is a valuable thing for society and for our community. Maybe it is willing to cop a much higher cost for those kinds of procedures if that is beneficial to the community more generally. It does not necessarily help low-income consumers more. Obviously, that is gaming at the more affluent end. Again, that is a question about the government's policy priorities: what is it trying to encourage? We support progressive models in those kinds of areas. We support those that are targeted at those people who cannot afford, those people who are on concessional benefits Therefore, being able to reach those thresholds quicker for those people who have less income is obviously a more progressive way to do it.

When you are dealing at that high, more affluent end where there are choices about whether you have the procedure versus whether you pay for the night's food, I think it is a different kind of policy choice for government.

Senator SMITH: So the decision to exclude concessional card holders from the threshold increase is a good decision from your point of view?

Mr Stankevicius : I am not sure I can say it is a good—I am not sure I understand the technicalities of that.

Senator SMITH: What we have here is a decision on the part of government to increase one threshold but to protect those who are, some might argue, the most disadvantaged in the community, those who are concessional card holders. So while not a perfect solution from your point of view, the decision to exclude concessional card holders is a better outcome than perhaps increasing the threshold across both groups or both classes of people?

Mr Stankevicius : It is but, again, are we are talking about this one that was simplified?

Senator SMITH: Yes.

Mr Stankevicius : I am getting confused. I think it is but, again, as I said at the beginning you will not necessarily find all people with chronic diseases, chronic illnesses or rare diseases on concession cards.

Senator SMITH: I agree.

Mr Stankevicius : There is that class of people who are in the middle of income disadvantage and affluent choices that are high cost that are still experiencing very serious growth in their health cost burden, which should be captured by the safety net. But obviously preserving it for the concession card holders is a good thing.

CHAIR: Thank you. We are over time, so if you could make it brief.

Senator PERIS: Just a quick question. In your out-of-pocket expenses survey, on page 4, it states: 'If you have a health concern, where do you usually go?' At the top it states, '82 per cent to a GP or a doctor.' It has a low range there of 1.7 per cent, who said 'hospital or medical centre'. What impact do you think this will now have on hospital and medical centres?

Mr Stankevicius : In terms of this one or the co-payment?

Senator PERIS: Both.

Ms Stephenson : With the proposed increase, the co-payment would obviously drive people to emergency departments if people are able to access them. After hours would limit that. With the proposed budget, with a charge at the ED as well, then neither choice may be financially viable and then you would have people not seeking care at all. That is extremely concerning.

Mr Stankevicius : The language around the proposed co-payment is a minimum of $7. The government has not proposed a level to any proposed ED co-payment. It is giving the states and territories flexibility. The last thing we would want to see is a patient shuffle between ED and GPs in the area where we essentially get GPs raising their co-payment to the same level as the ED or down a little or up a little. Consumers do not have that informed consent. If there are charges in the system and obviously we do not support co-payments in either, they should be set and set for a period of time and should not be able to changed from week to week. Consumers need to be able to plan those expenditures, particularly consumers with a chronic illness or rare disease. And if last week the co-payment was $7 but next week it will be $15, they need to know that. At least with the PBS stuff there is some certainty.

CHAIR: Thank you both very much. I would now like to call the witness from ACOSS. We have got very limited time with witnesses today, so if we could stick as much as possible to this bill, because we have got the out-of-pocket expenses inquiry coming up where we can go through everything.