Australia and NHI:Lessons - but no wizardry - from Oz
Gavin Mooney
Universities of Sydney, Cape Town, Southern Denmark, New South Wales and Aarhus
G’Day!
Overview
• Federal system
• Funding by both Federal (Commonwealth) Government and the States but C’wealth more.
• Provision by both Commonwealth and States but States more.
• Overall poor logic on who pays, who runs and who has responsibility
Total Spend
Getting on for 10.0% of GDP - and been rising
Breakdown of Total Spend
• 70.7 % Government (44.2% C’wealth; States 26.5%)
• 7.6% Private insurance
• 16.8% Out of pocket (private individuals)
• 4.9% Other
Who Provides What?
• Federal government funds universal medical services and pharmaceuticals; financial assistance to public hospitals, residential care facilities and elderly home and community care.
• State governments provide most acute and psychiatric hospital services; community and public health services such as school health and dental health
• Local government mainly environmental health
Public Financing
• Primarily (82%) from general taxation
• But (18%) from ‘Medicare levy’, with level of contributions based on income
Private Sector
• Exists more or less happily alongside public system
• Provides about 1/3 of all hospital beds
• Private insurance 7.6% of total health expenditure in 2008-9.
• June 2011 44.3% of population had private health insurance
PHI Premiums
• Community rated i.e. ‘non-discriminatory’
• Lifetime health coverage
• Most often not full coverage – hence “gap”
Private Health Insurance Rebate
• Tax rebates paid on PHI premiums
• Levels of rebates: 30% general population; 35% 65-69 years old; 40% over 70 years
• Rebate costs taxpayer $4.5 billion per annum
History of Medicare (NHI)
• Originally “Medibank” introduced 1st July 1975 as a result of unhappiness with existing voluntary health insurance scheme.
• To provide ‘the most equitable and efficient means of providing health insurance coverage for all Australians’.
• Political shuffling to 1 February 1984; then Medicare
Dr Neale Blewett on Medicare
• ‘A major social reform’
• ‘A health insurance system that is simple, fair and affordable’
• Provides ‘universality of cover’ which is ‘desirable from an equity point of view’ and ‘in terms of efficiency and administrative costs’.
1984 to 2011
• Some fiddling on benefits side
• Some fiddling on costs side
• But now accepted by all major political parties
• Part of the social fabric of Australia
Medicare: Great but Could Be a Lot Better!
• Careful in drawing messages for RSA
• Health and health care systems are or should be cultural phenomena
• So yes learn but do it the South African way
Some Thoughts from Australia
System makes it very difficult
• To set priorities
• To achieve equity
• To get debate on principles
What Do We Get?
Many of the problems of not having a single funder
• Lack of priority setting and hence inefficiency
• Lack of concern with equity and hence inequities exist, especially geographically
• Silly debate on who should pay, cost shifting and blame shifting
Who Sets Priorities in Australia?
• Not clear that they are set - at least not explicitly • Largely done by some form of osmosis behind
closed doors, with shroud waving and loud shouting, usually by blokes in white coats
• Emphasis very much on hospitals with continuing neglect of equity, community care, prevention and mental health
Priorities of Informed Citizens
• Equity
• Community care and prevention
• Mental health
• (To pay for these extras? Close hospital beds!)
Primary Health Care I
Dominated by GPs
Dominated by FFS for GPs
Hence
• not into health• not into population health• not into prevention• not into equity• not into multi-disciplinary care
Primary Health Care II
• Patient payments are for many unaffordable
• Undermines Medicare’s claim to provide equal access for all
Aboriginal Health I
• Medicare has failed Aboriginal people• Gap in life expectancy 11+ years• Policy based on horizontal but not vertical
equity (i.e. only limited +ve discrimination) • Institutional racism• Lack of cultural security• Too little spending and major gaps in services• SDH crucial but largely ignored
Aboriginal Health II
Basic problem
• White fellahs have been telling black fellahs what’s good for them for over 200 years.
• And we are still doing it!
Private Health Insurance Rebate
• Costs $4.5 billion per annum
• Does very little for health care or health
• Largely transfer of monies from general taxation to the well off - hence seriously regressive
• Money better spent in public hospitals
Hospital Cost Control
• DRG or “case mix” funding ‘to drive efficiency’
• Assumption behind this is that what hospitals are trying to maxmise is cost weighted cases.
• (Much better to use clinical budgeting for priority setting and try to maximise health)
Other Points
• Watch demand led services
• Keep patient payments to a minimum
• Multiple funders lead to multiple problems
• Get the critically informed citizens involved
The Buts of Oz Medicare
• Much to defend and admire in Medicare
• Difficult to contemplate Australia without it
• Does deliver according to key principles of NHI
• BUT....
Principles
• Universal but...
• Equitable but ...
• Efficient but ...
• Costly? no but ...
BUT Medicare Matters to Australians
• There are problems and eccentricities of the Australian system.
• BUT Medicare is now part of the Australian social fabric.
• A major social institution
• It aint perfect but ...
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