In memory of Bob Hawke, it's time for Medicare II
This article was first published in The Sydney Morning Herald
If a latter-day Bob Hawke were to introduce a universal health insurance scheme now, it would look little like the Medicare of today. It is time for Medicare II.
As we farewell Hawke, the father of Medicare, at his state funeral on Friday, we might do him justice by considering how we sustain his legacy.
Australia’s health system needs to catch up with the forces that are transforming health care – the growth in chronic diseases and, in contrast, the exponential advance and variety of expensive treatments.
If Medicare is to remain sustainable and retain access to quality health care for all, we will need reforms that reflect integrated care, and prevention, of chronic illness, and a system that ensures the array of modern treatment is cost-effective and affordable.
Australians take Medicare and the principle of universal health care largely for granted. Yet it is worth remembering that Hawke and his government had to push past the years of resistance to the notion of a universal health scheme that had haunted Labor since founding the predecessor scheme, Medibank.
Medicare, introduced in 1984, just a year after the election of the Hawke government, comprised a profound behavioural and economic transformation in the Australian health system. It did away with the then common reality of cost as a barrier to even routine doctor visits, of the pursuit of patients by public hospital debt collectors. It was a time when medical leaders argued for the patient “moiety”, or co-payment, as a virtue.
In the past 35 years, however, the world of health care has undergone deep change. Chronic disease, its treatment and its prevention pose the greatest challenge to modern health care.
Obesity is among the chronic illnesses increasingly afflicting the nation's health.
Medicare in its current form harks back to the days when the doctor’s workload had more to do with episodic services such as treatment of infectious disease and injuries. A typical caseload these days will be dominated by ongoing care for patients with chronic conditions such as diabetes, cardiovascular disease, cancers, arthritis, back pain, asthma and mental illness.
The Health Department estimates that one in two Australians has at least one of these chronic conditions. In many instances chronic diseases are preventable, yet Medicare and our health system overall takes little account of this, in either practice or prevention.
On the practice side, patients with such conditions benefit from team-based and integrated care focused on patient outcomes. But generally speaking, Medicare neither rewards team efforts nor patient outcomes.
We are seeing the pathology of a health system under strain, of universal access to health care increasingly being honoured in principle rather than in fact.
The federal government is trialling a form of new-look Medicare called Health Care Homes aimed at team-based care for people with chronic illness. The scheme features bundled payments replacing the current fee-for-service system to stimulate team-based care. The aim is to integrate the GP’s services with those of allied health practitioners such as pharmacists, physiotherapists and psychologists.
The government is also proposing to amend another aspect of pre-internet Medicare, changing payment rules to enable doctors to communicate with older people by phone and email rather than requiring every Medicare-paid service to be in person.
So we are seeing the first cautious attempts to pull Medicare into the 21 st century. But our 21st-century realities will require much wider change if Australia is to respond effectively to what we know are the causes of ill health.
The entire population would benefit if a Medicare II broadened the focus to preventive measures to encourage healthy diet and lifestyles. At the moment a tiny 1.4 per cent of the federal health budget is sprinkled on a range of preventive measures with little effect.
We need a comprehensive national strategy focusing particularly on obesity to counter the forces that nurture overweight children and adults – high consumption of unhealthy food and drink and barriers to routine physical activity.
Australia may be a comparatively healthy nation but a new study in the Medical Journal of Australia has found that, since 2003, life expectancy has increased more slowly than in most other high-income countries. It concludes that improved control of health risk factors such as obesity will be required if further substantial life expectancy increases are to be achieved.
Contemporary realities of climbing chronic disease, expanding cost and choices of treatment, and the focus of medical payments on episodic care, are turning Medicare into an anachronism.
If Australia is to rise to this challenge it should include systemic reforms worthy of the label Medicare II. It would require a great shift in established practice and thinking. But Australia has done this before.