Healthcare was always going to be at the heart of this election campaign. Setting the scene at the National Press Club in January, the prime minister mentioned Medicare nearly a dozen times in a speech laying out what will clearly be Labor’s election platform. Then, last weekend, he declared that a “stronger Medicare is at the heart of our government and it will be the beating heart of our election campaign.” Capping it off was $8.5 billion to boost access to bulkbilled Medicare services.
Labor is always keen to play to its apparent strength as Medicare’s creator and capitalise on voters’ belief that Coalition governments are more likely to cut or privatise health services. And opposition leader Peter Dutton’s rating as Australia’s worst health minister is too tempting a campaigning point for a government seeking to blame its opponents for the 2014–15 federal budget cuts — made during his ministerial tenure — that caused much of the damage it claims to be repairing.
Labor’s Mediscare campaigns have become a familiar feature of Australian election campaigns, and they work because almost always enough evidence exists to make the claims against the opposition credible. The campaigns are often posited in the terms Albanese used at the National Press Club: that the election is all about “a choice between two fundamentally different approaches and vastly different agendas.”
Labor recognises that access to medical care is increasingly difficult and unaffordable. Treatment costs for people with ongoing health issues are a major impost and too many are missing out on needed care. When medications and primary care are forgone, pressure grows on crowded emergency departments and hospital services. The reality is that Medicare no longer offers universal healthcare.
All of the causes of this malaise are widely recognised, but so far they have been poorly tackled. The increasing burden of mental health problems and the growing number of people with multiple chronic and complex conditions, combined with increasingly difficult access to community-based specialist care, imposes a huge burden on general practices. Delivering and managing this care is not adequately rewarded by Medicare payments. Additionally, Medicare payments have not kept pace with inflation and the operational costs for doctors and other healthcare workers.
These problems were made worse by the Coalition’s decision — under Tony Abbott, Malcolm Turnbull and then Scott Morrison — to freeze the indexation of Medicare rebates between 2014 and 2020 and pocket more than a billion dollars in savings.
For many years, Medicare rebates matched costs to the extent that doctors were able to bulk-bill most patients and faced constraints on what they could charge other patients in out-of-pocket costs. That constraint no longer exists, and the average out-of-pocket amount paid by a patient who isn’t bulk-billed has risen to $43.38.
Debate about the value of bulk-billing rates as a measure of affordable access is intensifying. But falling rates do indicate increasing costs for patients, and they do provide politicians with a simple way to laud Medicare funding efforts and criticise failures to provide adequate support.
Health minister Mark Butler and his colleagues have highlighted the positive impact of the tripling of bulk-billing incentives for concession card–holders and children under sixteen, which Labor introduced in November 2023. But independent research shows that the number of GP clinics bulk-billing patients has fallen over the past two years and bulk-billing is no longer available in one-in-ten federal electorates. The Coalition has seized on this data, with shadow minister Anne Ruston claiming that “it has never been harder or more expensive to see a doctor than under the Albanese Labor government.”
The reality is that only about 48 per cent of Australians are always bulk-billed when they see a GP, with a further 24 per cent usually bulk-billed. It’s a postcode and socioeconomic lottery.
Labor’s latest announcement looks to tackle this inequity by extending the triple bulk-billing incentive — previously confined to Commonwealth concession card–holders and children under sixteen — to all Medicare cardholders. It says this will deliver another eighteen million bulk-billed GP visits each year and boldly promises that nine-in-ten GP visits will be free of out-of-pocket expenses by 2030. Importantly, the new policy also tackles the need for an expanded primary care workforce by funding 400 hundred nursing scholarships and 2000 new GP trainees a year by 2028.
This quick bandaid solution to a complicated problem has been well received by voters and most GPs. So it didn’t take the Coalition long to realise that a me-too response would avoid the election trap that Labor had set. Dutton and Ruston announced that in government they will match Labor’s $8.5 million commitment “dollar for dollar.”
In a show of one-upmanship they also boosted their package to $9 billion by adding in a previously announced $500 million to restore the number of Medicare-subsidised psychology sessions to twenty. (In a controversial move, but based on expert advice, Butler cut the number to ten in 2023.)
We might justifiably be nervous about this announcement. It’s a big step for the Coalition, which constantly alludes to its conservative economic management credentials, to adopt such an expensive policy within hours of its announcement. Did they not have their own health policy proposals under development? But perhaps it should not be a shock given that the Coalition raced to match Labor’s $573 million women’s health package before it had even been launched.
We soon learnt that the Coalition health commitments will be paid for by cutting thousands of public servant jobs — essentially all the positions created under Labor to replace the very expensive outside consultants employed by its predecessors. Dutton has been open about his quest for budget cuts but says there will be no cuts in health. Is this believable?
Still, it looks like this approach to bulk-billing will be Medicare policy regardless of who wins the election. Will it work?
One problem is that the proposed funding boost doesn’t lift rebates, which doctors say are too low to cover the cost of longer mental health consultations and other common GP visits. Among the variety of responses from the medical profession, the president of the Australian Medical Association says that the $20 bulk-billing incentive won’t cover out-of-pocket cost averaging more than $40 in some metropolitan centres and better-off suburbs.
One key problem is that we know little about the business costs of general practice and how these vary by location. The increasing corporatisation of general practice may also be a factor determining what is seen as an appropriate financial incentive to bulk-bill.
A further challenge is making sure the healthcare workforce is available where it matters. More is needed than a simple increase in the number of training places. Despite improved training and a lift in the supply of specialist rural GPs, an August 2024 report projected an overall under-supply of GPs over the next twenty-five years.
One way to tackle workforce shortages and simultaneously improving health outcomes is to look beyond general practice to primary care more broadly. When done well — as it is by Aboriginal Community Controlled Health Organisations and in community health clinics — coordinated and multidisciplinary care can very effectively meet patient needs. The primary-care workforce includes GPs, nurses, nurse practitioners, allied health professionals, midwives, pharmacists, dentists, and Aboriginal health practitioners, paediatricians and geriatricians.
This integrated approach is hindered by fee-for-service funding and medical organisations’ opposition to non-clinical members of the primary care team being given direct access to Medicare payments. But viable reforms have been proposed by a range of expert groups convened by both political parties.
In fact, every major review of the healthcare system over the past quarter-century has recommended moving away from an excessive reliance on fee-for-service. The Morrison government’s Primary Health Care 10 Year Plan and the current government’s Strengthening Medicare Taskforce Report and Review of General Practice Incentives all point to the need for more flexible blended payment models, especially for treating people with chronic and complex conditions. If GPs are mollified by increased Medicare funding and if Labor gets a second chance at governing, maybe an idealist could hope such reforms could happen?
Even assuming that an increased investment of $8.5 million improves access to GPs, or — optimistically — that efforts are made to expand access to primary care services, a huge and expensive gap remains: the availability and affordability of out-patient specialist care. Medicare now covers just 52 per cent of specialist fees, forcing Australians increasingly to dip into their own pockets. In 2022–23, out-of-pocket costs for private patients for specialist consultations amounted to $2.3 billion. Those who can’t afford private fees are left to languish on public waitlists.
New public hospital agreements with the states and territories might include sufficient funds to tackle these long waiting lists (although this would be unlikely under a Coalition government). The National Health Reform Agreements were recently extended for just one year as negotiations continue over state and territory responsibilities, especially in relation to the NDIS, with a funding increase for 2025–26 of 12 per cent and a one-off contribution of $1.7 billion.
One final plea. To improve health outcomes and eventually reducing the pressure on the healthcare system from preventable chronic conditions such as obesity, diabetes, cardiovascular conditions and now long Covid, government policy makers need to including healthiness in the healthcare system. Lip service is paid to the importance of prevention and the need to tackle the social determinates of ill-health, but these issues can’t be handled adequately within a healthcare system that is relentlessly focused on illness.
All of the necessary reforms will take time, investment, vision and bravery. The process must start with solid initial commitments that are continued, expanded, refined and supported over the decades ahead. That means a bipartisan approach that looks at Australians’ health needs well beyond the next election cycle. And that means the major political parties must drop their political ideologies and gotcha campaigning. It’s a lot to ask, but the dividends could be enormous. •
