First published: Thursday, July 24, 2014

THE REAL AGENDA: PRIVATISATION AND SAFETY NETS, NOT COPAYMENTS.

Much has been written about the proposed copayments for health care. It has surprised many that the Federal Government has pushed so hard so fast to attack bulk billing and to increase user pays funding of health services. This has led to a superficial unity of resistance to the changes. But these proposals need to be seen in both a historical perspective and alongside the other less publicised proposals and suggestions from the Government.

Just before the 2001 election John Howard commented on the introduction of Medibank which was the Whitlam version of Medicare introduced in 1974, reintroduced as Medicare by the Hawke Government in 1984.

” That was the cardinal mistake that we made with our health system in the 1970s when Medibank was brought in. …………..in the process we destroyed the honorary system and we dismantled a perfectly functioning health system…” (1)

Under his guidance and later on with Tony Abbott’s help as Health Minister, two major changes occurred in the health system. First, the private health insurance (PHI) and private health system were promoted and the Federal share of funding for public hospitals fell from 50% to 38%, leaving the States to struggle and patients to wait. This resulted in a marked expansion in the pre-existing mildly two tiered access to elective surgery. The second step was to encourage the demise of GP bulk billing by letting the value of the rebate decline. The rate dropped from 80% to 68%. The Government smelt success and then danger. The backlash from marginal electorates threatened defeat at the 2004 election. A mad policy scramble and backflip lead to a 20% increase in the rebate and the addition of bulk billing incentives, such that GP Medicare income increased by at least $40,000 per annum, enough to encourage GPs to bulk bill more patients. The attack on public hospitals and promotion of private hospital care had worked. The attack on bulk billing had failed. Thirteen years in office. Two steps forward and one step back in the battle to destroy Medicare as we know it.

With the election of the Abbott Government the battle continues. The absence of any good economic or health outcome arguments for the proposals indicate that the agenda is purely ideological. It would be a mistake however, to believe that the Prime Minister did not expect a significant backlash. He knows from his previous experience that there is a problem. Australians like Medicare and bulk billing. The solution to the problem is a gradual re-education process across multiple electoral cycles as necessary. The aim is to change perceptions, to remove the understanding that Medicare is public health insurance with premiums according to means and benefits according to need. This needs to be replaced by an understanding that Medicare is a safety net only, and that those who can afford to pay should do so, usually through private health insurance.

This process of re-education started under the Howard Government. There is now a widespread appreciation in the community that if one needs elective surgery, it’s best to have private insurance. Increasingly, the same applies to a variety of non elective hospital based interventions such as heart procedures, cancer therapy, and midwifery. In the last years of the Howard Government, Joe Hockey changed the name of the bureaucracy running our public health insurance from the Health Insurance Commission to Medicare Australia to limit anyone thinking that they already had health insurance i.e. public insurance.

Building on those successes, the Abbott Government has proposed an end to bulk billing and a 15% increase in prescription medicine prices. Whilst these changes may fail to pass the Senate as proposed, the opposition to the proposals is far from united. The Australian Medical Association is in negotiation with the Government and it is important to understand that its position is not that it disagrees with copayments, but rather that it wants doctors to be able to decide how big the copayment should be and who are the deserving poor requiring cost reductions. It simply wants doctors to maintain control and continue to play God. It claims as justification the primacy of the doctor patient relationship. It fails to explain however, why such a relationship, important as it is to health, must also involve a financial component controlled by the doctor. The Royal Australian College of General Practitioners (RACGP) has a similar view as stated

“However, the RACGP recognises many patients are in a position to make a contribution to the cost of their healthcare and therefore supports GPs’ freedom to determine a fair and equitable private fee for their services.”(3)

This approach leaves patients at the mercy of doctors’ variable knowledge of patients’ financial circumstances and the variable attitudes and beliefs of doctors as to who is a member of ‘the deserving poor’.

The Labor Opposition has rejected the proposals but it is important to recognise how conflicted and therefore how political rather than ideological this rejection is. In the 13 years of the Hawke/ Keating Governments the PBS copayment doubled in real terms (2) and a GP copayment was introduced briefly by Hawke in 1993. During the Rudd/ Gillard Governments no attempt was made to reduce PBS copayments despite the existence of similar data to that which has been displayed in the last 6 months indicating that copayments reduce use, particularly amongst the most disadvantaged. In addition the 2013 freezing of the GP rebate by the Gillard Government indicates that economic and political factors are more important than any concern about the effect such changes might have on patient access.

What this budget has done however, irrespective of whether the copayment proposals come into force, is to open the debate on user pays, on the concept of ‘pay if one can afford’, and has revealed considerable acceptance of that principle which the AMA, the RACGP, and the ALP support to varying extents.   For the Government, this is success. This is despite the fact that such an approach conveniently ignores the reality that patients who are in a position to contribute more have already done so through the paying of their public health insurance premiums i.e. through taxes; thus they pay twice.

The complexity of the GP copayment proposals may well be as big a barrier to implementation as the general opposition the proposals have evoked and the presence of an uncertain Senate. This can still be a win for the Government in their battle to re-educate the public about how our health system should work.

The place of private health insurance in the Government’s agenda is crucial. The next step in this re-education process is to convince people that PHI should be a part of primary or community based health care. Legislation exists which prevents PHI coverage of copayments for visits to doctors. But an ongoing trial by Medibank Private funds administrative costs of a general practice and offers improved access for its members. Thus, it avoids the spirit of the legislation clearly designed to ensure that the poor have the same level of access as the rich. The Health Minister Mr Dutton has indicated interest in the trial. Indeed his position on PHI involvement in primary health care was clearly articulated at the National Press Club post budget

‘I believe very strongly that their (PHI) money is wisely invested earlier in the process, invested earlier in the process so that they can help me address some of my lifestyle choices which might prevent me from becoming diabetic, or from suffering from heart disease otherwise’.(4)

The obvious consequence of such an approach is to two tier access to primary health care. The lifestyle choices of the uninsured, often much more limited anyway than the rich, can be ignored. That is part of the plan.

The PHI industry is waiting in the wings, convinced that it is the solution to quality care, happily ignoring the reality that whatever it does, it only does for those who can afford PHI.

The expansion of copayments also helps to highlight increased calls by those who can afford PHI to allow coverage of copayments. Sufficient public support for these changes is essential and will not be immediate but it can develop slowly, over more than one political election cycle.

The next step is to further erode the capacity of the public hospital system to manage demand. This is at the heart of the decision to axe the National Health Reform Agreement, reneging on $1.8 billion funding over 4 years and abandonment of activity based funding. Over several decades these changes would have seen a gradual increase in the Federal Government’s percentage of public hospital funding. But if the public perceives public hospitals are struggling more, the appeal of private hospitals and PHI increases. The re-education process continues.

Medibank (the original Medicare) was introduced in 1974 as a system of funding health care through taxes. Prime Minister Malcolm Fraser spent the next 9 years trying to replace it. It was a very messy and complicated task and contributed to the Hawke victory of 1983. Medicare was introduced and has had 30 years to become embedded in the Australian psyche. But the concerted attacks on it from the Coalition have had an impact, aided to some extent by an internally conflicted Labor Party. The concern for those who hope for an equitable health system is not the success or failure of the copayment proposals; it is the step by step erosion of the various parts of the health system and the gradual move to increasing reliance on user pays and safety nets.

In the neoliberal vision of our health system, the poor will have a safety net, the quality of which will depend upon the vagaries of changing political and economic factors. Low income workers will struggle with copayments and long waiting times. Middle income earners will enjoy the benefits of PHI unless severe or chronic illness reduces their capacity to pay and they consider mortgages to fund adequate care. The rich will have whatever they want except the opportunity to live in a society which values all its citizens.

Tim Woodruff
Vice president
Doctors Reform Society

1. John Howard 2001, Sydney Morning Herald, 27 October, 2001

2. Australian Government Department of Health. Fees, Patient Contributions and Safety Net Thresholds  History of PBS Copayments and Safety Net Thresholds

3. Friday facts newsletter: 20 June 2014 RACGP releases official position statement on co-payment

4. National Press Club Address 28^th May 2014

First published: Friday, December 12, 2014

The inequities in the status of oral health in Australia are appalling because of a lack of political will and a resistance to recognising that all Australians deserve to receive adequate dental care. This resistance is rooted in the elitism of those in power, the belief that if one can’t earn an adequate income, then second rate access to dental care is one’s lot.

The money to improve access is available, whether from the inequitable inefficient $12 billion private health insurance (PHI) subsidy and associated tax losses, the putative savings of $100 billion over 10 years which the Treasurer says would be the cost of Labor tax initiatives, or general revenue used to invest in the future as we are doing with our $50 billion submarine contract.

Recent posts on this blog from John Menadue and John Dwyer point out the many sad statistics on oral health status, accessibility to care particularly for those on lower incomes, the lack of preventive care, and the continued failure to address social determinants of poor oral health. The Essential Report based on survey results from February 2018 found that 48% supported the redirecting of the PHI rebate to dental care with 20% not having an opinion.

A simple solution to oral health? Certainly a $12 billion investment would go a long way to providing adequate dental care to all Australians. The 2012 Report of the National Advisory Council on Dental Health (NACDH) stated that

‘The Council’s discussion of a particular model for a universal scheme in the short‐ to medium‐term did not receive unanimous support from all members.’

Thus, universal access to comprehensive dental care was not even considered. Why would it? We don’t yet have universal access to comprehensive medical care in Australia despite claims to the contrary. We have universal access to an inadequate rebate for doctor delivered services in the community and limited non-doctor services, all dependent on provider availability which is determined by providers. We have guaranteed access to public hospital care if one can wait long enough. We have access to subsidised medicines if one can afford the co-payments (taxes on illness) imposed by the government. It is all much better than pre-Medibank (the precursor to Medicare) but it is not universal health care.

Instead the NACDH considered options for access to limited dental care, with or without some means testing, targeted to some or all children and poorer and sicker adults, delivered either through a Medicare style rebate with provider determined optional co-payments, or through State public dental services. These options were seen as potential steps towards a more universal system. The most expensive option which reached all 5.4 million children and over 7.6 million adults was estimated to cost $2.5 billion yearly in 2012, using the public system as the service provider. Using private dental and fee for service cost $5.1 billion yearly.

In 2013 the Labor Government under pressure from the Greens, committed to an amalgam of the above, with limited means tested fee for service access for children and a National Partnership Agreement with the States for limited means tested access through the public system for eligible adults. The intention was to gradually build on the services, increasing accessibility to more patients and increasing capacity of the system. Instead the Coalition Government has effectively reduced both components of the plan, reducing the amount available to the States for adult care, not indexing the cap for child care, and not addressing the issue of patients requiring much more than just the basic level of care.

So where to from here? Can we heed the suggestion that dental care should be a standard part of any health system? That is difficult because we don’t have a health system. We have multiple poorly connected silos, funded in multiple different ways with world class emergency and urgent care in public hospitals, dedicated health professionals struggling to help patients negotiate the maze of care, and frustrated and at times desperate patients and relatives trying to negotiate the maze whilst governments continue to fiddle at the edges of the ‘system’. An integrated system which recognises dental care is required.

Funding is needed. It is available within the health budget. Whilst the ex-Prime Minister Tony Abbott said that ‘PHI is in our DNA’, it may be time for some genetic engineering as PHI is also well entrenched in the Labor Party. However Labor has committed to a Productivity Commission review of PHI which would reveal what most know i.e. PHI is grossly inefficient. As a first step a gradual reduction in the PHI rebate could be used to fund public access to hospital care and at the same time scale up the current dental policy as was originally intended, with a long-term view of moving to a truly integrated universal health system, inclusive of oral health. The public consistently express the desire for improved health care, even to the point of paying more taxes. Are there any political leaders who see equity as a principle to underpin policy rather than a point of differentiation from an elitist Coalition?

I reached boiling point last week after spending an hour on the phone trying to get a taxi subsidy for one of my patients. There are plenty of boxes to tick to get a taxi subsidy, but specifically you need a specialist letter confirming you cannot walk 20 metres without assistance. So what about a woman in her 70s with multiple problems who can usually walk 100 metres slowly, who has just had a major operation?

This case was a medical emergency. My patient was expecting to be discharged from hospital within 48 hours. She was worried about her ability to shower alone, let alone walk 20 metres or drive herself to her dialysis treatment, which she needs three times a week to stay alive.

Her story had been clearly outlined to the paper-pushers. But they still asked me for a specialist letter. So which specialist? The kidney specialist who can talk about the renal failure? The joint specialist who will only write that she can walk 100 metres usually? Or the surgeon who didn’t have time to write the letter himself? I went with the surgeon – and wrote it for him, emailing it to his secretary for his scribble at the bottom.

Continue reading “GPs need to be recognised as the specialists they are – DRS”

As a financially comfortable part time medical specialist, I will be in the group receiving the highest tax cut immediately, whilst my daughters working full time at much lower income will receive about one third of that. It’s of even more concern, that in seven years’ time, the major beneficiaries of the Government plan will be those on incomes like that of politicians, receiving eight times more in reduced tax compared to low income earners.

Whether it’s Labor or the Coalition everyone wins eventually, or do they?

The Government promises that by 2025 the rich will pay $7225 less tax yearly, middle earners will pay $675 less, low income earners will be a paltry $200 better off, and for those on $20,000 or less nothing will change. Even in the short term, the Government favours middle income earners over low income earners and gives nothing to those on very low incomes.

Labor does better. It makes no long term promises, but in the short term it gives middle earners $1067, nothing to the rich, taxes the very rich more, but curiously it only gives $350 to low income earners and nothing to those on very low incomes.

How does this relate to health? Poor people are sicker and die younger than middle income earners, who in turn are sicker and die younger than rich people. In last years’ Boyer Lectures Sir Michael Marmot, the former president of the British Medical Association and international leader on the social determinants of health explained this social gradient of health. Essentially it is the degree of control over one’s life which is crucial to health and wellbeing. In a supportive community/ family setting this social gradient of health is less apparent. Although poverty is not destiny, income is generally a huge component of this sense of control. Nor is it about absolute poverty, but rather it relates to relative poverty, the difference in incomes across society. This has been starkly documented by British epidemiologists Wilkinson and Pickett in their book The Spirit Level.

Given its elitist philosophy, it is hardly surprising that a Coalition Government may pay little heed to such evidence based concepts which, if addressed, would lead to improved heath across society. One might expect however that it would be interested in the effects of inequality on productivity. It is worth noting the comments regarding this in 2017 from Christine Lagarde, director of the International Monetary Fund:

“However, if we look at inequality within specific countries, especially some advanced economies, we see widening gaps and an increased concentration of wealth among the top earners. IMF research has shown that excessive inequality hinders growth and hollows out a country’s economic foundation. It erodes trust within society and fuels political tensions.”

One might also expect more from the Labour Party, whose Health spokesperson Catherine King welcomed Michael Marmot’s visit to Australia last year with these comments:

“Only Labor is committed to tackling health inequality, and to improving the social determinants of health across all portfolios”

So what happened?

There were small but definite and useful health-specific policies from both major political parties along with Government cuts to childhood dental funding and minimal extra commitment to prevention and primary care, but at the same time their tax policies increase the income divide across sections of our society. One has to wonder how Labor, supposedly the party of the workers, could promote a policy which increases the income gap between low and middle income earners. Under Labor, a worker in Aged Care, perhaps looking after a politician’s elderly parents, will receive just $350 a year and a pension dependant parent of that same politician will receive nothing. But for both parties, it is all about an election policy. The justification therefore may be that neither party expects those on low incomes to change their vote. So they don’t matter.

These new tax policies are definitely not about health or the welfare of struggling Australians. They do not promote equity or a fair go. Sadly they are all about politics from Coalition leaders who either do not support the concept of equity, or Labor leaders who either pretend they support equity but are closet elitist, or are incapable of instituting in their own party the principles and policies which promote equity and health.

In 2017 I referred a patient for relatively simple orthopaedic surgery on her wrist to enable her to get back to working in a café.  She had been advised that she was a category 3 patient and should be operated on within 365 days. During this period she couldn’t do her usual part-time work which she could juggle around child care commitments. Furthermore, Centrelink required her to apply for jobs she couldn’t do. It took 6 months to even get on the waiting list. She finally had the surgery 15 months after I referred her.

Another of my patients had a similar problem. Retired, it stopped him playing golf. He was operated on within a month and is happily back on the golf course. He had publicly subsidised private health insurance (PHI).

Both received high quality health care except for the time delay for the first patient.

Labor’s proposed inquiry

The Labor Party plans to have a Productivity Commission inquiry into the private sector if it wins this year. It has released a consultation paper regarding what terms of reference the inquiry should have. It lists 6 principles underlying its approach. It is reassuring that the first principle is

‘A commitment to Medicare as a universal health insurance scheme that provides every Australian with the highest quality of health care regardless of where they live and their capacity to pay.’

Timing of surgery is an integral part of ‘the highest quality of health care’. The stated commitment therefore requires that Labor address this major problem.

The next principle relates to the ‘finely balanced public/private mix’.  It does not mention that with evidence like the above, we currently have a very unbalanced public/private mix which results in patients and their families exposed to avoidable suffering because they can’t afford PHI. The other 4 principles are about improving the quality and affordability of private health insurance.

Labor finds itself on the horns of a dilemma. It doesn’t want the PHI rebate to be an election issue. Labor is a broad church and many in the party and their supporters believe that as high earners they deserve faster access to elective surgery than lower income earners. The cost of the PHI rebate to taxpayers is $11 billion. It helps richer patients avoid long public hospital waiting lists. It is inefficient and inequitable. But even those Labor politicians who accept that are understandably worried that ‘disunity is death’.

Fundamental contradictions

Despite that, the deeply concerning thing about this paper is its failure to recognise that the first principle is completely at odds with simply improving the quality and affordability of publicly subsidised PHI.   Health budgets will always be limited, and continuing taxpayer support for PHI at a cost that is 10% of total Government outlays on health care is incompatible with timely access to care for those who will never have PHI and rely on the under-resourced public system.

The biggest threat to PHI and to the private hospital industry is a publicly funded health system which fulfils the first principle Labor has listed ‘provides every Australian with the highest quality of health care’. The paper details some suggestive questions for the Commission but they are all about improving PHI. None are about the first principle. Instead, or at least in addition, Labor should be asking the Productivity Commission to look at the most efficient way to fulfil that principle.

Combining that principle with efficiency would be very productive. If that is what the Commission was asked to do we would at least be able to start considering the major changes required to address the problems of equitable access. This could include a gradual reduction in the PHI rebate with a corresponding increase in resources for the public hospital system and primary health care, or consideration of a hospital benefit as has been suggested by the Department of Prime Minister and Cabinet a few years ago.

Running away from answers

Labor appears to be running away from getting the real answers despite the fact that all this would happen after the election, and therefore pose minimal threat to the result. It is either completely lacking courage or is so intimately committed to the privatisation of our health system despite its rhetoric, that it is not prepared to even consider asking the right questions.

Meanwhile another of my patient continues on her narcotic analgesics as she waits for her total hip replacement, supported by her daughter who takes time out from her own family to help her mother deal with the multiple doctors’ visits and the narcotic induced nausea and constipation. It’s only been 6 months since I referred her.

She’s finally on the list and will probably be operated on within 365 days as hip replacements are generally Category 3 urgency and over 95% manage to get surgery in that time as the guidelines suggest. That’s a year out of her life which is almost entirely avoidable if politicians decided it was a concern.  Her bowls mate is back on the green 4 months after being referred for her surgery. She has publicly subsidised PHI.

ALP health spokesperson Catherine King addressed the National Press Club this week to expound Labor’s vision of health care changes if it wins office. Perhaps the highlight of the address was a restatement of Labor’s vision

‘of a truly universal health care system in which every Australian has affordable access to the high-quality health care they need whenever they need it.’

But will such a vision be wholeheartedly pursued under a Labor Government?

She spoke of some of the problems that we all know exist in our health care. She recognised the lack of affordable and timely access to care as a major problem, although she failed to mention the 7% or more of the population who delay or don’t fill prescriptions because of Government imposed co-payments. Due mention was also made of the problems of chronic disease and complex needs. Examples of inequitable access and outcomes indicate Labor knows what the problems are and appreciates their importance.

Recognition of the need for reform to achieve this vision was apparent. Some of the barriers to reform were detailed: the split funding and responsibilities of Federal, State, and Local Government and the short political cycle with alternative governments trashing previous governments’ attempts at reform.

Apart from the expected pre-election rhetoric, the centerpiece of the presentation was the commitment to a permanent Health Reform Commission.

‘It will be a body explicitly charged with reducing health inequality and improving the universality of our health system’

‘comparable to the Productivity Commission’

Thus, it would be expected to give apolitical advice to guide the development of policy in health care, with the particular focus mentioned. Early attention to expanding public hospital outpatient clinics and primary health care models would indeed be welcome. Combined with the stated restoration of lost public hospital funding and immediate unfreezing of the Medicare rebate, this sounds like a very good direction to address the many issues of concern.

Its power will reside in the quality and acceptability of its advice. As with all Productivity Commission recommendations, the decision to act on that advice will depend entirely on our elected representatives. They will continue to fight amongst their various parties and levels of government. Changes may occur, but they may be reversed at the next election. Every concern outlined in the address regarding the disappointing history of reform will remain.

It’s worth remembering a 2012 Productivity Commission report into problem gambling. The recommendation was to progress to an Australia wide poker machine pre-commitment system—under which players could set spending limits on all poker machines—by 2016. A Senate committee recommended this be mandatory. The Gillard Labor Government watered this recommendation down to voluntary and of course the Abbott Government rescinded the lot.

The Productivity Commission has no real power. It is advisory. The suggested Health Reform Commission has no real power. It is a potential force for good only insofar as its suggestions can fit with the barriers to reform outlined by Ms King in her address, which do not look as though they will change even in the medium term future.

But as has been pointed out by John Dwyer on this blog previously

‘the commission must have the authority to implement change and have a vision for ten years of continuous improvement’

The vision may well be developed by such a commission. Without such authority however, lasting reform will be minimal. Perhaps hidden in the political strategy is an intention to consider giving such authority to the Commission as it evolves. Without such intention Labor cannot move significantly towards its stated vision.

But Labor is not even demonstrating it is interested in getting useful advice about big picture items like the private health care system. Government funds 30% of the costs of private hospitals (AIHW Australia’s Health 2018) but the proposed Productivity Commission ‘root-and-branch review of the entire private healthcare system’ mentioned in the presentation ignores this funding and in particular the Private Health Insurance rebate (see my previous article on this). As well as suggesting a basic lack of knowledge of botany, such reluctance to even seek advice does not bode well for the usefulness of the proposed Health Reform Commission.

Labor’s health policy direction is positive. It is so much better than that of the Coalition which however does set a very low bar. To date however, Labor has not demonstrated it is pursuing policies to achieve its vision.

With this approach we will continue to have health care but not a health system. The perspective for our patients and their families will not change. The nightmare for them consists of multiple poorly connected pieces: the public hospital system, the publicly subsidised private hospital system, the GP system, the publicly subsidised private specialist system, the community care system, the publicly funded private allied health system, the mental health system, the private dental system, the publicly funded private dental system, the public dental system, the Aged Care system, and a myriad of other pieces. We can do better.

First published: Sunday, May 27, 2007

General practitioners get lots of mail.

At the top of my batch yesterday was a shiny green pamphlet that simply asked “Who’s really at risk of contracting hepatitis B?” It smelt like advertising so I cast it aside to open later.

Next up came a letter from a local dermatologist who wrote that my patient had been prescribed a particular brand-name cream. I couldn’t recall its active ingredient and flung the correspondence onto a check-my-facts pile, while quickly repressing the thought that this mightn’t have been necessary if I saw pharmaceutical company representatives or read drug ads.

Opening the next letter caused a distinct surge of relief. By strange serendipity it was about the very same cream. I wouldn’t need to check anything!

On closer inspection, the letter proved to be an apology from the manufacturer for “misleading and unbalanced” promotion of the drug. Maybe the dermatologist had facts to check too.

I figured, not for the first time, that it’s just as well I avoid drug reps-I can’t expect myself to filter expert propaganda from corporations richer than many countries.

Even Gardasil, the genital wart virus immunisation typically requested by young female patients as “the cervical cancer vaccine”, is more than just an Australian scientific success story. It’s a marketing juggernaut.

So much so, that the Federal Opposition attacked the government for pausing the vaccine’s rollout during price negotiations. Of course, haggling over the cost was only needed because the developer, Commonwealth Serum Laboratories, had been flogged off during a 1990’s government sale of family silver. This privatised profits and CSL’s share price has increased nearly ten-fold during the biotech boom in recent years … but that’s another story.

Like many GPs, I’m currently doling out taxpayer-funded Gardasil vaccines as fast as stocks arrive-but that doesn’t mean my only concern has been the more-painful-than-average injections.

Qualms about Gardasil initially seemed unpatriotic or even misogynistic. Misgivings are now common, and include its cost, its marketing as the solution to cancer of the cervix when at best it’s expected to prevent about two-thirds of cases, the incorrect and dangerous perception that it might make Pap smears unnecessary, and the difficult question of the best age to give a vaccine whose effect might yet prove to wear off before many recipients even start having sex.

Thing are often more complex than they seem. Some years ago there was a campaign, apparently initiated by a patient support group, to caution against generic prescriptions of anti-epileptic drugs. The concern was that subtle differences in bioavailability compared with more expensive brand name drugs could cause fitting.

The media and experts at the time seemed to overlook that severe epileptics are often stabilised in public hospitals, so I made a few phone calls. It turned out that public hospitals used cheap generic drugs. Contrary to the well-funded campaign, it seemed prescribing brand name drugs might be dangerous!

I then tried to speak to the neurology professor making media appearances to raise awareness of the possible hazards of generics. I didn’t get past his secretary but asked her if the Prof was a drug company lackey. For some reason, she thought I was joking.

Industry relationships are claimed to be educational so it’s recently been suggested that doctors attending drug company events should be publicly identified. The professor chairing the Australian Medical Association’s Therapeutics Committee commented that this would be “a major tragedy”. He might be supported by the 27% of US medical school and major teaching hospital departmental heads who are also paid consultants to the pharmaceutical industry.

Fortunately, the pendulum in medical circles seems to be swinging away from the solicitations of Big Pharma. These days, refusing to see drug reps is often regarded as endearing eccentricity rather than dubious weirdness.

Amid squeals and to their credit, a number of Australian medical colleges have released tougher recommendations for dealing with my profession’s corporate sponsors. This is probably just as well when block-buster drugs like Vioxx are regularly busted by trials or meta-analyses.

Of course, even a meta-analysis isn’t always what it seems. A recent review found that those funded by pharmaceutical companies, compared with those done without industry support, are less transparent with fewer reservations about methodological limitations of the included trials, and have more favourable conclusions than the corresponding Cochrane reviews.

Anyway, back to the question of “Who’s really at risk of contracting hep B?” A quick squiz inside the pamphlet has just revealed the inconvenient truth-it’s nubile women in bikinis.

The Doctors Reform Society are proud to sign a new open letter to Australian parliamentarians asking for significant commitments to carbon pollution reduction. This has been written as we approach the important UN conference in Paris in December 2015. We are but one of 51 diverse Australian organisations signing this letter.

A FAIR GO OR SHOULD WE TAX PEOPLE WHO ARE UNLUCKY ENOUGH TO BE SICK?

Do our leaders believe in a fair go? The Prime Minister has stated that he and Lucy have been lucky and observed that “there are taxi drivers that work harder than I ever have and they don’t have much money”. One might expect that such recognition of the place of luck (genes, family support, education, freedom from illness or exposure to trauma) in achieving wealth and the security that goes with that would lead to the development of policies which minimise the place of luck in our lives. But timely access to affordable health care, first class education and justice before the law remain a struggle for many. It appears that both major political parties are quite happy to pursue policies which entrench the importance of that luck. An examination of our health system highlights this.

My patients who earn $36,000 a year pay $36 for most prescriptions. My patients who earn $360,000 pay the same, and those on $3 billion pay the same. Usually, these prescriptions are for conditions which can’t be avoided, it’s just bad luck. This government imposed co-payment is a tax on illness. It is not noticed by those on $360,000 but for those struggling on $36,000 or pensioners who pay a reduced tax on illness of $6 per prescription, this does affect their small disposable incomes. It is a regressive tax.

The effect on patient behaviour of this regressive tax on illness is well documented. The Australian newspaper commissioned a Newspoll Survey in 2011 and reported that 18% of those earning $40-79K delayed or did not fill a prescription due to cost. Slightly lower figures for the whole population from the Australian Bureau of Statistics Patient Experience survey (10%) and the Commonwealth Fund survey (14%) indicate that underuse is a major consequence of such co-payments. The Commonwealth Fund survey has also looked at sicker Australians and found not surprisingly, that the figure rises to 20% for them.

So much for the Government imposed tax on illness, the prescription co-payment. There was also the general practice (GP)  co-payment in its many forms. The ALP’s Senator Wong labelled it quite correctly a tax on illness. That label has fallen from the ALP lexicon, presumably because they realise that the prescription co-payment they support is also a tax on illness.

But we are left with doctor determined co-payments.  This is the so called co-payment by stealth, whereby the Government has frozen the indexation of the Medicare rebate resulting in a gradual decline in GP and specialist Medicare income, forcing doctors to either accept a salary decrease or charge co-payments. Both major parties have applied this freeze, claiming it needed to be done as a savings measure. The Coalition however has been clear about its other intention which is to force doctors to charge new or higher co-payments and discourage use. This intention is based on the flawed Commission of Audit report suggesting patients were seeing doctors too often. To date the bulk billing rate hasn’t fallen but over time doctors are unlikely to accept the $18000 decline in their income from Medicare. New or higher co-payments will be charged. Some doctors will have standard co-payments whether the patient’s income is $36,000 or $360,000 and the Coalition knows this will be the result. Is such a regressive tax on illness fair?

The claim by our leaders is that such taxes on illness are necessary to ensure that people value the service and don’t overuse it. The hypocrisy of this claim is demonstrated by the facts. Both major political parties support the laws which have been passed to encourage  ‘no gap’ private health insurance (PHI)  for hospital care which, when it works properly, ensures that there is no price signal, no co-payment for repeated admissions to a private hospital in any one year. In addition, the Coalition supported a 2014 trial in general practice (GP) which eliminated co-payments for GP visits for those covered by PHI. It would appear that our leaders believe that some taxes on illness are necessary only for those who can’t afford PHI. Is that fair?

We have a progressive tax system which exists as a recognition that the market delivers income to people very unevenly and if we are to have a civil society which respects and supports people irrespective of luck, we need to redistribute that income. Taxing illness does the opposite. It redistributes advantage to those on higher incomes.

It would seem that our leaders, attitude is “I have made it, I plan to stay comfortable. You are unlucky. I might help you a little, but I’m not changing the system to minimise the place of luck in getting to my position of security and wealth.” Elitism and entitlement rather than a fair go would appear to be the principles driving most of our leaders.