Issue 34 / 15 September 2014

IT’S almost 40 years since the Whitlam government introduced a publicly funded universal health care scheme called Medibank, which became Medicare almost 10 years later.

We were the twelfth nation in the world to introduce universal health care.

Now an Australian government seems intent on destroying the battered principal of universality — access to health care that responds to individual need, not individual income — that has survived despite the gradual erosion of the real value of rebates by successive federal Labor and Liberal governments. And it is set to do it with the perhaps unwitting assistance of the AMA.

Under the government’s proposal, Medicare rebates will be cut by more than $3.5 billion, with GPs to collect a $7 copayment from each patient for each occasion of service. The proposals are deeply unpopular. The effect on the less well off would be devastating.

In an attempt to ameliorate the worst of those effects, the AMA has proposed changes that include:

  •  No cuts to the Medicare rebate
  •  No obligatory copayment for children, concession card holders, chronic disease and mental health
  •  Elimination of the 10-visit threshold for children, concession card holders, chronic disease and mental health.

These exemptions from the proposed copayment represent a thinner, more acceptable wedge with which to cleave Medicare asunder. It terminates Medicare’s universality as effectively, if less cack-handedly, than the government’s proposal.

I have no objection to those who can afford it paying more for their medical services as an arrangement between themselves and their doctor. In fact, given the sustained assault on the real value of Medicare rebates, it is essential that doctors have this option so they can afford to continue to bulk bill those in need, as the majority of doctors already do.

However, patients paying according to their means should not be at the expense of access according to need. That is the principle that lies at the core of universality, and that is what is at stake.

The AMA represents a profession whose primary concern is the health of its patients and the government is seeking to introduce a policy that directly attacks that concern. There are other means to address the issue of inadequate rebates and underfunding. In my opinion, the AMA has no legitimate role in seeking to make the copayment more palatable if that is at the expense of universality.

All this may prove moot as the Senate is tipped to reject the government’s proposals, although there is always a chance deals will be done with the crossbenchers.

In the current political climate, given the unpopularity of the copayment proposal, one thing is certain — if the AMA had opposed it, this policy would have been delivered to the Senate already stone dead. Instead, it may have facilitated the delivery of Rosemary’s baby to the electorate, attractively disguised in silk wrapping.

Who do you think the government — and more importantly the people — will blame when the full effect of the loss of universal health care hits home?

Dr Michael Gliksman is a physician in private practice. He is a past vice-president of the AMA (NSW) and a past member of the AMA Federal Council. The views expressed here are his own.
Find him on Twitter: @MGliksmanMDPhD



Do you support the AMA’s proposed amendments to the federal government’s copayment for medical services?
  • No – AMA should oppose copayment (64%, 50 Votes)
  • Yes – it’s a good compromise (24%, 19 Votes)
  • Maybe – still needs work (12%, 9 Votes)

Total Voters: 78

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12 thoughts on “Michael Gliksman: Risky policy

  1. N5278@amamember says:

    While completely opposing any co-payment for GP consultations, I would remind members that there has been a co-payment for the Pharmaceutical Benefits Scheme for many years and this currently reaches over $30!   Despite this significantly increasing the cost to patients before the safety net cuts in, I do not recall the hysteria over the GP co-payment applying to the PBS co-payment.  Go figure!

  2. Greg Hockings says:

    Dr Gliksman, like many politicians and media commentators, confuses the concept of universally accessible health care with that of free health care. The idea of a price signal to minimize unnecesary medical consultations is valid and effective.  Any service which is perceived by the public as being free is undervalued and over-utilized. Patients have responsibilities as well as rights and there should be a financial incentive to encourage healthy lifestyles, medication compliance, etc. The medical profession had much greater respect before bulk-billing and “free” consultations, and patients were generally more compliant and health-conscious. Geoffrey Miller’s comment is interesting. The PBS, like all health services, does not have infinite resources and so funding choices have to be made. It is not unusual to read of life-saving but extremely expensive cancer drugs being unavailable on the PBS, or at best greatly restricted in their availability. Yet how many millions of dollars does the PBS spend annually subsidising the cost of relatively cheap medications for treating lifestyle-related conditions such as hyperlipidaemia, type 2 diabetes mellitus and hypertension? Choices have to be made if we are to have a sustainable health care system and a national budget free of debt and deficit. I for one am quite prepared to resign from the AMA (after 30+ years as a member) if it opposes the co-payment outright.

  3. Michael Gliksman says:

    No matter the debate, no matter the position taken, there are always those who threaten to resign if their personal preference is not translated into AMA policy.

  4. Greg Hockings says:

    For the record, I have not made this “threat” previously in my 30 year + membership of the AMA, despite inevitablly finding myself in disagreement with some of its policies at times . I do not do so lightly now. I would very much prefer to remain part of the profession’s umbrella organization and attempt to influence change from within. I believe that the profession would be significantly weakened without having an organization which can effectively represent it politically. However the co-payment and the related broader issue of bulk-billing are of such fundamental importance to the future of sustainable health care in Australia that I would, reluctantly, have to give serious thought to resigning if the AMA were to follow Dr Gliksman’s advice, especially if the majority of AMA members completely oppose all forms of co-payment.

  5. John Stokes says:

    Whether you support gaps or not the large Copayments (gaps) charged by many procedural and other specialists (supported by the AMA) makes a mockery of any criticism or complaint by the profession or the AMA of a $7 copayment. The hypocrisy is staggering and makes sensible doctors shake their heads in disbelief.

  6. George Hamor says:

    I agree with John

    The copayment stops after 10 visits. This equates to $70 p.a.

    To think that this is a huge burden for the  “disadvantaged” is ridiculous.

    The comment by Greg the Physician is also very true. The concept of universality does not equate to free health care.  Something that is “free” is bound to be abused and unappreciated. Yet is has to be paid for by “someone”.

    Govenments have conned us for years about “free health care”.

    The only way the system can be sustained is if there is some kind of means testing so that the truly poor can access timely treatment. This however is aso a contentious point.

  7. Michael Gliksman says:

    IMO The above encapsulates the problem. $70pa is per person, not per family. That may not be a minor expense for families living below the poverty line. For them this is no ‘price signal’, it is a price barrier, as the policy intends. For those for whom it does represent a price signal, those like me, it is sufficiently low as to make no difference at all to our behaviour. It is, in fact, yet another transfer payment from the poor to the better off. As a member of the pr-eminent caring profession, I find it deeply offensive.

    However I do agree re the hypocrisy inherent in specialists like me charging what we like while our GP specialist colleagues suffer a constraint we don’t.

  8. Dr Louis Fenelon says:

    I get to post a comment to a mate from med school, as well as one of our professors in one night – first time for that!

    Michael, thank goodness for your admission there is a ridiculous and indefensible line between how specialists have never and will never see (or accept) the AMA demanding a government dictate their income, or even raise the question of morality of fees.  What is going on here with government, GPs and the AMA is typical of the way general practice and the doctors who do it have been treated by the AMA for decades.  

    Since when did individual general practitioners, responsible to all their patients at all times during and after treatments, without the support of institutions like state health departments, who also take that responsibility to their family via income, deserve to become scapegoats in the cost of medical care in this country.  It is not a question.  

    The Australian GP saves our system money.  Medicare wastes money and always has.  People seem to blame doctors for that, when in fact Medicare has given patients blank cheques to spend.  The co-payment means nothing to me as I am not part of any public health system and nor am I a charity.  I cut all but the very bare bones of my bulk-billing on hearing about the co-payment.  It’s not my responsibility and I don’t want to spend hours justifying anything to do with it next year.  My personal income dropped by 10% last year due to increased, long and maybe less than effective bulk-billed consultations.  I won’t call it bulk-billed medicine, because a lot was just paperwork.

    Government leads GP’s by the nose ring. The AMA cares 0 for GPs. I resigned years ago.  It’s all up to me!

  9. Peter Bradley says:

    Bravo, Dr Fenelon..!

    Makes some very good points.  As senior GP, now approaching a woefully prepared for & funded retirement, precisely because of the issues discussed above, I feel only sadness, that because I chose General Practice, I basically condemned myself to being cheated of the chance to look back on my GP career with pride and a sense of satisfaction, because it has cost me dearly. 

    People need to know that this Australian health system only survives and provides such excellent & affordable primary care largely because of the largess of the majority of the GPs providing it.  We are virtually forced to support the social welfare system in doing this out of our own pockets.  GP rebates are so low now it’s disgraceful.  Medicare consult now  = half a Workers Comp. visit.  (Which is same as AMA recommended fee) 

     If something drastic is not done soon and by whatever means, to lift GP remuneration/funding, we will drift over to a system like the US is trying to break out of. Patients having to self refer to specialists because they can’t see a GP.   And before anyone starts in on saying “it’s your own fault, just charge what you think you are worth and be damned” – don’t..!   If you are practising in a relatively low socio-economic area, or one where there is a large BBing corproate practice nearby, it is well nigh impossible to not BB, or you just go out of business. I know..!



  10. CKN Queensland Health says:

    My experience working in a disadvantaged area would suggest $70 per person p.a. would represent a major burden, particularly for families.  Maybe some of my professional colleagues here aren’t quite in touch with real-life struggles of many Australian families.

     eg 4 kids all with school sores from infected mozzie bites. Can’t attend school until treated with antibiotics. $40 plus medication plus public transport for the 5 to see you.  That is a dent on a low-income budget. I won’t advocate for a health system that disadvantages kids like this.  There are intelligent ways to save money. This is not one of them.

  11. Paul Jenkinson says:

    Even with the current dire state of GP economics and a future with the majority of the population being cared for in impersonal corporate GP factories,only 35% of respondents to the accompanying survey think there is any merit in the AMA submission! If that is a true indication of how the profession values GPs, it is really very sad and a further indication that a move to nationalised medicine will not see an effective opposition from the profession.Where will all the UK escapees go then?

  12. Sandy Robertson says:

    NO co payment is the answer! I was working with Medicare (HIC) when it came in many years ago and the administration nightmare for Health Professionals was terrible! So I go with the NO vote…I though the last thing they would reduce is health care!

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