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First published: Sunday, April 26, 2015 8:20PM

Are co-payments dead? Or is that the sound of Medicare’s last gasps?

The GP co-payment is dead. So said the Prime Minister as he made his third retraction on the issue six weeks ago.

However, co-payments are far from “dead, buried and cremated” – and analyses of recent policy announcements suggests we are heading ever faster towards a two-tiered, US-style health system

Health Minister Sussan Ley’s recent announcement of reviews of  efficiencies in primary care and the Medical Benefits Schedule is welcome, but should be recognised as merely a strategic change of tack that leaves the overall policy direction unchanged.

The $5 cut to the Medicare rebate has gone, but the four year freeze on the rebate remains. This means that the Medicare rebate will not be adjusted for inflation for the next four years for GP, allied health, dental, and specialist consultation.

For GPs this is effectively a $3 rebate cut over four years, which is a clear signal to GPs that they should start charging co-payments to more patients – or face a $15,000 salary cut. The Government prefers the former and will probably get it.

The AMA continues to object to the freeze of the rebate primarily because it forces doctors to decide to accept a pay cut or charge co-payments to make up the difference. It is important to note however, that the AMA recommends a $36 co-payment at the discretion of the doctor.

Whilst the Government and the AMA are in ongoing negotiations, they do share a common aim. They and the Royal Australian College of GPs (RACGP) all want a reduction in bulk billing, claiming that many can afford co-payments whilst conveniently ignoring the fact that those who can afford a co-payment already usually pay more in taxes to support Medicare.

The RACGP should be commended, however, for its proposal to improve and extend blended payments, moving away from reliance on fee for service and co-payments.

Reports suggest that a part of the new plan will be to make it easier to charge a co-payment. This can be done by allowing doctors to just charge the co-payment up front and separately apply to Medicare for the rebate.

With such a proposal the patient has to pay the co-payment but completely avoid the hassle of sorting out the rebate.  This will make it easier for doctors to start charging a ‘little’ co-payment, e.g. $5, with minimal impact on patients who can afford to pay.

It would entrench in patients’ minds that co-payments are to be expected, that bulk billing is for the really poor, and that Medicare is a safety net. This is the intention, despite the reality that Medicare was set up as public health insurance for everyone, not as a safety net.

This is one step towards the further privatisation of our health system.

Once this re-education process of the public has begun to work, the brake on co-payments will be lost and the amount will quickly rise to what the AMA wants and recommends i.e. $36, or more.

The next step to privatisation will be to have private health insurance (PHI) cover co-payments (gaps) just as they do in private hospitals. The Federal Government is already supporting this. It has expressed its approval for a trial in 26 medical centres in Brisbane where Medibank Private guarantees for its members no co-payments (price signals), same day appointments, and after hours GP home visits within 3 hours.

For any of the medical centres to be able to do this, they must downgrade access to care for patients who do not have PHI.

Most Australians dealing with chronic diseases know that access to elective surgery is grossly unfair. Now the Government wants the same unfairness to extend to access to GPs.

In addition, the PHI industry has been accepted by the Government as players in Primary Health Care Networks. The industry’s interest is their members, not the population at large.

Meanwhile, ongoing Federal cuts to public hospital funding increase public concern regarding hospital access and encourages them to take out PHI, strengthening the hand of the PHI industry.

Co-payments are far from dead. They are alive but unhealthy, preventing access to care for some of the most disadvantaged Australians. They are growing.

The intention of the Government is to make them grow much more, so that those who are on incomes low enough for the co-payment to be a price signal do stop using services.

No such restriction is to be placed on those who can afford co-payments or PHI.

Those who stop using GPs or taking their drugs because of co-payments may die because doctors and drugs save lives. Co-payments are not dead but they cause deaths by stopping people accessing life saving care, whether it be seeing a GP because of chest pain which could be indigestion or a deadly heart attack, or not taking a drug which over 10 years definitely reduces the likelihood of someone dying.

The change in tack of the Abbott Government from directly imposing extra costs on patients to these more subtle measures reflects a much smarter approach to achieving the long term agenda: the destruction of Medicare as public health insurance for all, and its replacement by an American style private system for the rich and a second  rate public system for Aussie battlers.