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Anne-Marie Boxall delivered the presentation at the 2014 Future of Medicare Conference. The Future of Medicare Conference was a timely event as the Abbott government debates a full over haul of the Australian healthcare system. This conference presented a chance for government representatives, regulators, health care providers in the public and private sector, educators and private investors to come together and debate the proposed changes to Medicare as well as discuss the best practice methods of implementing new measures and frameworks. For more information about the event, please visit: http://bit.ly/FutureofMedicare2014
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UNIVERSAL HEALTH CARE IN
THE 21ST CENTURY
Dr Anne-marie Boxall
Director, Deeble Institute for Health
Policy Research
Australian Healthcare and Hospitals
Association
THE DAWN OF THE 21ST CENTURY
W I N S T ON C H U R C H I L L
“THE FARTHER BACKWARD YOU CAN LOOK, THE FARTHER FORWARD YOU ARE LIKELY TO SEE”
Medibank developed in 1968
Designed to address problems of the day
Access to GPs, medical specialists, and public hospitals
Acute illness and injury
OBJECTIVES OF MEDICARE
THEN AND NOW
Simplicity
“The simpler we make a health scheme the more chance it has of delivering the services to those who need them most”
Affordability
“Everyone will contribute towards the nation’s health costs according to his or her ability to pay”
Universality
“Medicare will provide the same entitlement to basic medical benefits, and treatment in a public hospital to every Australian resident regardless of income”
Efficiency
“Having the maximum number of health dollars spent on delivering health services rather than administering them”
Neal Blewett , Second reading speech, Par l iament 1983
KEY FEATURES OF MEDICARE
Does universal access to health care matter?
Is Medicare still universal?
What can we do about it?
CRITICAL QUESTIONS
DOES UNIVERSAL
HEALTH CARE MATTER?
The WHO says so
All WHO member states (includes Australia) made a commitment to
achieving universal health cover (World Health Assembly, 2005)
The UN explains why (UN General Assembly 2012)
It is the right of every human being to the enjoyment of the highest
attainable standard of physical and mental health
WHY DOES UNIVERSAL CARE MATTER?
IS MEDICARE
UNIVERSAL IN THE 21ST
CENTURY?
Free access to public hospitals remains
Waiting lists for elective surgery can be long PHI have preferential access
Almost 2/3 of all elective surgery in private
hospitals 75% in some speciality areas
Access to private hospitals limited No PHI, or living in rural and remote areas
LIMITS OF UNIVERSALITY - HOSPITALS
Bulk-billing rates for medical services
High for GPs (83%)
Low for medical specialists (28%)
Access to doctors very limited in some
areas
LIMITS OF UNIVERSALITY – MEDICAL
CARE
Jurisdiction Bulk-billing rate (all services, %)
ACT 65.8
WA 71.1
Tas 74.1
Vic 76.6
Qld 77.5
SA 78.1
NT 85.0
TOTAL 77.4Data: Medicare Australia, March 2014 quarter
VARIATION IN BULK-BILLING ACROSS
STATES
GP bulk-billing rates (2010-11 data)
46% Canberra, Fraser (ACT), 57% Curtin
(Perth, WA), 59% Higgins (Melbourne, VIC)
99% Chifley, 98% Fowler, Blaxland (Western
Sydney, NSW)
LOCAL VARIATION
Federal budget 2014-15
$7 co-payment on all previously bulk-billing GP,
pathology and diagnostic imaging services
MBS rebate reduced by $5
Only applies for first 10 visits for concession card holders,
children <16
Low Gap Incentive Payment paid if these people are only
charged $7 co-payment
Possible end of bulk-billing threat to universality
PROPOSED CHANGES TO BULK-BILLING
MEDICARE ≠ HEALTH SYSTEM
Medicare is not the entirety of health system
Insurance scheme that covers medical and hospital services (small range of allied health services)
Many other health programs and initiatives funded through various means
Preserving universal health care cannot rely entirely on Medicare (without radical reform)
WHO FUNDS HEALTH CARE?
Australian
government
43%
State/territory
governments
27%
Health insurance
funds
8%
Individuals
17%
Others
5%
Federal government
E.g. PBS, ACCHOs, mental health services, dental health
State governments
E.g. Community Health Centres, drug and alcohol programs, child health clinics
Private health insurers
Hospital care, some out of hospital and ancillary services, ambulance services
OTHER PROGRAMS AND INITIATIVES
AUSTRALIAN GOVERNMENT FUNDING
MBS/PBS, 35.6Payments to
states, 15.1
Rebates for PHI,
4.7DVA,
3.6
Medical
expenses
rebate, 0.5
($billion), 2011
MBS/PBS
Payments to states
Rebates for PHI
DVA
Medical expenses
rebate
Universality of Medicare being eroded but
need to look beyond Medicare to solve the
problem
Two longstanding problems undermining
universality
Fragmented financing arrangements thwarts quality care for
chronic disease
Mixed public-private health insurance with unclear roles
ADDRESSING PROBLEM OF UNIVERSAL
CARE
Medicare established alongside PHI scheme
Voluntary PHI scheme in place since 1950s
Medibank layered on top in 1975 – mixed public/private insurance model
Various experiments with balancing mixed system
Today - Medicare is universal, but 47% also have private insurance
Structure of our mixed system a problem that needs addressing
UNIVERSAL INSURANCE + PRIVATE
INSURANCE
Private insurance covers some of the same services as Medicare (duplicative insurance) Hospital treatment
Some allied health services
Private insurance covers some additional services and benefits (supplementary insurance) Dental services, optical products
Additional allied health cover
Medical specialist fees in private hospital
Private insurance cannot cover some Medicare services GPs
ROLES FOR PHI IN AUSTRALIA
THE ROLE
OF PHI IN
VARIOUS
OECD
COUNTRIES
S OURC E : OE C D
H E A LT H AT A
G L A N C E , 2 01 3
Large duplication between Medicare and private
insurance has never been addressed
Duplication means people with PHI sometimes
have: Faster access to health care
Access to a wider range of services
….sometimes they also have higher out of pocket costs
While some people have privileged access,
universality is being eroded
PROBLEMS WITH DUPLICATION
WHAT CAN WE DO TO
MAINTAIN UNIVERSAL
ACCESS?
Universal access being eroded because haven’t tackled longstanding problems
Not easy public policy problems to solve
Tendency to look at small-scale financing solutions (co-payments and safety nets)
Should we consider larger-scale structural reforms? They are always contentious
Little detailed policy analysis/modelling underway
CAN WE FIX IT?
Clarifying role of PHI Limiting role to covering optional extras (no govt subsidies)
Opt-out system where Medicare and PHI compete (must cover
primary health care)
Alternative health system models Allow people to cash-out government benefits and control own
funds (Medical Saving Accounts)
Allow third-party to control funds and manage care (Health
Maintenance Organisations)
SOME OPTIONS
We don’t have a clean slate to work with
Medibank and Medicare built on existing system (FFS, insurance model and strong private sector)
Future reforms will be strongly informed by current arrangements
Reform is not easy
Labor’s long campaign for Medibank
Helps to have well developed policy proposal
Failure is often a stepping stone to success
Medibank dismantled but paved way for Medicare
New policy proposals often pragmatic solutions to problems
Medicare contested ALP policy
Bipartisan support (publicly), ideological positions harder to determine
PROSPECTS OF REFORM: LESSONS FROM
HISTORY
Our health system increasingly not meeting its
objective of providing universal access to health
care
Need for reform, but problem not just Medicare
Thinking about reforms in infancy and analysis
limited
‘In a society as wealthy as ours there should not be people putting
off treatment because they cannot afford the bills. Basic health
care should be the right of every Australian’
Neal Blewett, 1984
CONCLUSION
Contact details
Dr Anne-marie Boxall
Director, Deeble Institute for Health Policy Research
Australian Healthcare and Hospitals Association
QUESTIONS?
