The politics of health

Australian nurses can play an important role in achieving a health system that is more equitable, says Dr Gwendolyn Gray, adjunct fellow in the School of Political Science and International Relations at the Australian National University.

Dr Gwendolyn Gray, who has a special interest in the way health and welfare policies affect women, told members attending the 2013 NSWNMA Professional Day that ethical and philosophical differences between Australia’s two major political parties meant Australians had seen massive changes to the health system under different governments.

“A health system provides, or not, an appropriate range of services. It ensures or it doesn’t ensure geographical access to services. It ensures or it doesn’t that financial barriers to service use are non-existent or negligible. So how well does the Australian system do? The general answer is ‘not very well,’ Gwendolyn said.

The Liberal Party of Australia primarily takes the view that healthcare is a product to be bought and sold in the market place just like any other.

“The concept is not to harm but not to be responsible either to provide conditions to prevent illness. In this philosophy government plays only a minor role,” Gwendolyn said.

The view favoured by the Australian Labor Party is that communities can provide for themselves through government, that medical need, not ability to pay should be the basis for access to services. That even if some citizens work hard to get themselves out of poverty, somebody else will fall back in because market societies work with a residuum of around about 20% to 30% of people who are on no, or very low, income.

The changes in the Australian health system in the past 70 years reflect both views in varying degrees:

In the 1940s a federal Labor government introduced the nation’s first free hospital system, paying the states to remove hospital fees. Opposition from the Australian Medical Association (AMA – then called the British Medical Association) prevented it from introducing other changes, including a national salaried medical service and medical benefit and pharmaceutical benefit schemes.

In the 1950s the Menzies Coalition government forced states to reintroduce hospital fees or forego federal assistance. Only Queensland refused and received no federal money from 1951 to 1975 when Medibank began operating. The Coalition also introduced the AMA-supported policy of subsidised private health insurance with one third each paid by the government, the private insurer and the patient. “As far as I know, Australia is the only place in the OECD where we’ve had direct public subsidies of private health insurance,” Dr Gray said.

In the 1960s, amid intense criticism of the Menzies scheme, on access and equity grounds, a South Australian study showed that unpaid hospital bills were the largest cause for imprisonment for debt in the state. “The patient share of medical costs rose as doctors raised their fees. Because, when the government increased its benefit, the doctors increased their fees. So the gap for the patient remained exactly the same.”

In the early 1970s the Whitlam Labor government restored free hospitals and removed subsidies for private health insurance. In 1976, despite vociferous criticism from the medical profession and the Liberal National Party Opposition, it introduced a publicly funded universal health care system, operated by the government authority Medicare Australia to extend health care coverage to all.

In 1976 with the Coalition back in power, Australia become the first government anywhere in the world to abolish a major national health system and replace it with an old one.

“This is typical Australian politics where in the past, and I won’t say that this exists so much now, there were major ethical and philosophical differences between the parties. They aren’t so strong now, but the basis of the two party outlooks are still those social liberal and market liberal views that I outlined to you,” Gwendolyn said.

She said there was a huge imbalance of political power around health policy.

“The groups on the producer side are strong, the medical unions, the private health insurance industry, the private hospitals, the big manufacturers, they’re strong.

“But where are the consumer coalitions, the consumer groups? They’re very weak.

“It’s said that behind the two [Labor] governments that introduced national health insurance, against great political odds, was a coalition of groups consisting of unions, of women, of people who wanted less racism in society – a coalition of left-leaning groups.”

The time for further change may come again, Gwendolyn told the audience, and if it does these same forces will need to come together to balance the influence of the dominant players; the medical unions, the pharmaceutical manufacturers, the technological manufacturers, the private health insurance industry and private hospitals.

“We’d have to ensure public control of the system as opposed to private market-based control. We’d have to ensure universal access to hospital, medical and allied services including geographical access and removal of financial barriers. We’d have to establish a network of primary health care centres, and in regional, rural and remote areas they’d have to be staffed by salaried or contract based personnel because if they had fee-for-service people working in them, the charges would prevent the sickest people, those in most need, from using the services.

“Nurses could play a very strong balancing role in moving toward the kind of health system that would be more just and more equitable.”