Viewpoint: Putting health back into the system

Kamala Emanuel

Putting health back into the system

The health spending bidding war between Labor and Coalition politicians reflects the fact that Australians have indicated that health is the political issue of greatest concern, next to unemployment. Around 88% of Australians also support the public health fund Medicare — up from 45% in 1983. The level of private health insurance has dipped to around 36% — down from 68% in 1982. The squeeze on the public health system caused by increased demand and inadequate funding is reflected in blow-outs in hospital waiting lists and closures of beds, wards and hospitals. The Liberals have promised a $500 million package of incentives to take out private cover. Although the details are not yet out, one of the proposals canvassed is to pay a subsidy directly to the private health funds, who would then offer discounted premiums to target groups. The compulsive belief that the private sector and market are more efficient than the public sector drives this approach. The facts are otherwise. Writing in the Canberra Times on June 15, Crispin Hull pointed out that the tax office and Medicare take only 4% of the health "premiums" they handle, while the private funds take about 13%. Labor is more focused on cutting public health spending by improving "productivity". Hence its proposal to reward a cut in hospitals' elective surgery waiting lists over two years with an extra $150 million in grants, and new Medicare agreements with the states to improve hospitals' efficiency. The formula to improve hospital efficiency is based on the case-mix funding used in a number of states. "Efficiencies" arise by allowing hospitals to keep any surplus generated through cutting costs. The most common savings result from the same treatments being administered in less time, therefore reducing hospital stays and waiting lists. The result of this system in Victoria has been competition between hospitals for patients with diagnoses attracting higher funding, and restrictions on patients attracting lower funding. Small country hospitals with more chronically ill or elderly patients requiring longer stays have faced closure. According to a 1994 Royal District Nursing Service survey, many more patients were being readmitted because they had been sent home too early. Both parties' approaches are based on the view that health should be treated as something to be purchased on the market. This degrades public health services, preventive health care and action on the root causes of poor health — poverty, poor working conditions and a poisoned environment. A quality public health system is a right, not an expensive commodity. It requires a transition from "fee-for-service" medicine. We need a system of salaried health professionals and public pathology and radiology services, working with elected community health boards. Keating's 50% rebate for families needing health services not covered by Medicare has only halfway addressed a real problem. Medicare should be expanded to cover the range of medical services not currently covered. The Medicare levy should be abolished and Medicare paid for out of general income taxes, which should be scaled more progressively. Public hospitals should receive increasing funding until waiting lists are eliminated, high technology services are matched to community need and the wages and working conditions of health workers raised to a reasonable level. The special needs of the rural population, Aboriginal communities, women, migrants, young people, the mentally ill, people with disabilities, old people and their carers should be met by adequately funded, community-controlled services. We need a public pharmaceutical manufacturer and price controls on multinational drug companies. Most of all, we need health delivery to be accountable to the community.
[Dr Kamala Emanuel is the Democratic Socialist candidate for Newcastle and spokesperson on health.]