I am going to talk, as I was asked, about the bigger picture in terms of the politics and healthcare reform and the challenges of thinking innovatively in healthcare and healthcare policy and healthcare practice in the ways we just been hearing because of the way that the political scene works in relation to health and Medicare in general.
I’m going to give you a bit of a case study from my experience as the GP copayment guy. It’s all my fault, the entire problems of the healthcare system are all my fault. Tony Abbott, when I went around with him as his senior advisor, used to say to people “I’m Tony Abbott, I’m the health minister, I do all the good stuff. Terry Barnes is my senior adviser, he does all the bad stuff”, so clearly that’s followed me through the rest of my career. So I’m going to talk about the GP copayment experience as a case study in a sense, and then I’ll draw some lessons for health care reform from that and I might ask a couple of tough threshold questions which I think that innovators and policymakers should keep in mind, particularly as we look ahead to the needs of the Australian population in the next decade or two.
So in terms of the politics of reform, the GP copayment and Mediscare as in the election campaign showed how diabolical it can be to pursue structural and efficiency reform in the Australian health care system. Basically, to talk about changing the settings of Medicare is like killing Bambi. Voters value what they can see they have, Medicare is clearly a sacred cow.
The copayment experience really highlighted that and the fact that Labor was able to run such an efficient scare campaign which almost got them to office on the basis of really nothing, because people perceived they were losing Medicare as they understood it. This became a disaster for the government. On top of that, the sector is infested with powerful practitioners, experts and vested interests that are all convinced that they know absolutely best and that the government, state and federal, they’re there merely as payers for their grand schemes and ambitions and what they think is appropriate. And on top of all that is we saw with Mediscare it’s too easy for opponents of change to distort, mislead and even lie to ensure that they get what they want or the status quo remains.
Governments and political parties attempting to place restrictions or conditions on access to healthcare therefore run a very risky gauntlet. Even positively and relatively benign reforms like the healthcare in the home concept, and I actually think the health innovation communities concept as well, change relationships between patients, providers and payers, and therefore threaten the status quo so you have to expect a storm of opposition to come down upon you.
So is up to governments and advocates of change to make clear how that change will work, what the benefits will be, and how patients, consumers and taxpayers will be better off. And from my own experience it also means that you have to be willing to make a blood sacrifice to the ravenous Bug Blatter beast of Traal, for those of you who remember Hitch-Hikers guide to the Galaxy, which is actually known in Australia as the Australian Medical Association.
Having said that though, in terms of the politics of the present health care debate I fail to understand why the Turnbull government went into the recent election campaign without health policy. It had a couple of announcements including the health care home trial but when you think about it, the last time a government went for re-election or an opposition went for an election without a clear, coherent, narrative for its health vision was 1990 when Peter Shack actually stood up just before the election and said sorry, we don’t have a health policy.
We saw a repetition of that. I think it actually cost the government, because they couldn’t factually respond to Mediscare and the rest is history in that respect. The fact that although they almost lost the election on Mediscare, I haven’t seen any real evidence of them forming a narrative after the election and, more to the point, making it clear that they see health and health reform, and health policy and the stability of the system as a top priority for the second term Coalition government.
On the other side, what have we got from Labor? Basically we have had for the last few years, really since the copayment broke in the end of, just after the Abbott government was elected in December 2013, is just push back. It’s just been all negative. It’s just been “I hear your pain, so I’ll throw money at all that bad things governments have done and make it better for you”. Put a Band-Aid on it and kiss it better!
And the election campaign itself was basically, besides the fact it was founded on a lie, all the health policy that labour put forward was of that nature. It was, I wrote recently, that the real imitator of Donald Trump in Australian politics is not Pauline Hanson but actually Bill Shorten, because of the populism that under his leadership the Labour Party is resorting to, and therefore is actually creating a big problem for the healthcare conversation, health policy conversation in general.
But on the other side, the government doesn’t have a clear sense where it’s going so that actually creates very fertile ground for scare campaigns, for uncertainty, and for making discontent.
So with that, I’ll tell you about my own experience of my thoughts about GP copayment debate which in political terms came from nowhere and just blew up as a story that just kept on going – and now I’m the GP copayment guy, the “architect” of the government’s ill-fated plan according to everybody who doesn’t realise that I had nothing to do with the government’s plan.
They did their own thing, they just let me run the debate before they were ready to go public. It got currency because of the fact that just after government was elected, I did a paper for another think tank called the Australian Centre for Health Research and it was reported that it was being put to the Commission of Audit – and the PM at the time Tony Abbott was asked about the idea of a copayment but didn’t confirm or deny anything in true budget speculation style. So off we went and it was on for young and old. And really what happened over the next year or so, I think, has really set the cause of health reform back are a long, long way and I’m personally quite so sorry for that.
But instead of rightly being a second-order structural efficiency measure which is the way its bought forward, no magic bullet and it was never a magic bullet, never intended to be. It was meant to be part of suggesting how the system could be made more effective, more robust and more patient and payer responsive. It was not intended to be the single solving problem, the measure to solve the problems of the system. The copayment became an ugly cackling hag that hijacked the political policy agenda.
Besides the fact it wasn’t the magic reform bullet the implacable opposition and resistance of vested interests, especially Brian Owler and the AMA, was totally underestimated and the budget decision itself to link the outlay saving to a humongous Medical Research Fund, instead of recycling those savings if they don’t do something political into health and hospital services and infrastructure was mystifying and totally out of left field, politically naive and frankly a big big mistake.
What the government really didn’t do before that budget 2014 was read the politics of the Senate and therefore gauge the chance of the enabling legislation passing. They thought that they would have a better chance after July 14 with the new Senate including people like Jacqui Lambie and the Palmer United Party, but how wrong they were. They needed to start making a rational policy case of greater patient contributions for primary care. They didn’t. There is a genuine equity argument that says people on higher incomes shouldn’t expect bulk billing is right and should actually contribute in some way, according to their capacity, to help those less well off, but we never heard it.
The government didn’t start sending a message to those who could do so, they must do their bit but they didn’t understand details and implications of what they were proposing in many respects. Post- budget estimates hearings revealed that modelling of the copayment to measure was minimal or non-existent, and I understand a lot of the thinking actually happened in political offices, not in the bureaucracy or using expert advice.
They certainly didn’t take my advice or at least consult me on my experience in trying to explain the concepts publicly.
The other issue which is key here is that it showed that it was primarily the government was concerned not about access and efficiency but about booking budget bottom line savings in 2014. So they rushed to judgment to get a proposal out there so they could actually have a figure in the budget papers that could actually show that they are reducing our debt and deficit. And the government’s subsequent attempts to refine and then redesign the copayment plan later in 2014 and into early 2015 did not make things better, in fact I think they make things a lot worse.
The government and its key ministers; health ministers, treasurers are prime minister even didn’t quite look like they knew what they were doing. Improvements were actually more complex and messier than the copayment mark 1, and again the government’s attempts at explaining and defending these changes were awful.
The change of minister in December 2014 in my view made little difference but the fallout from the whole copayment debate and the political outcomes were a disaster for general healthcare reform.
Both the Coalition and Labor adopted a common position when you think about it and that is this: that they, be it the Labor Party all the coalition parties, will not pursue difficult reform in healthcare unless the medical profession is on-board, and in practice that means that the AMA is the arbiter of who comes to Medicare and the circumstances in which they come.
And despite the AMA leadership changing from the outspoken demagogue Brian Owler to the far more reasonable and moderate Michael Gannon, that hasn’t really changed. Really the AMA sets the pace here. Jeremy and Peta need to convince Michael Gannon and his members that what they are proposing will work if it is ever going to succeed. And whether that’s are a good thing you can make your own judgement. I don’t think it is a good thing.
What the government should have done is this: One: It should have started tilling the ground well before the 2014 budget, perhaps even before the 2013 election notwithstanding the political risks to get public acceptance of the need for some reform around bulk billing and patient contributions.
Clearly it needed to explain what the problem was, and there is a problem. Certainly, if you are going to change the system and given that Medicare is such a social sacred cow, you need to be able to start talking sooner rather later. But, because of budget secrecy, neither confirm nor deny what’s in the budget, they didn’t do that. They were quite happy to let me be the canary in the coal mine – and as you can see I’m not the best communicator in the world – but they wanted to see if I suffocated and died in the political hothouse of the copayment debate. I didn’t. I’m quite proud of that. I was actually able to prosecute a case publicly and in the media. And in writing. To actually show that this could work and it had a reasonable basis to it.
But the government didn’t realise, they said “If Terry can do it, we can do it too”. The thing is, I was just an obscure former government advisor doing a paper for an obscure think tank, not the Treasurer and the Prime Minister and the government of the country, making this measure the centrepiece of a tough budget. They just didn’t expect the flak they got because they thought, the actual debate in the run-up to the budget is relatively benign in broad political terms.
They did not set the whole plan in a wider health policy but also in a wider fiscal and general reform context. They didn’t actually tilt the ground themselves. They may have flagged, they could have flagged, their intentions instead of going for the 2014 budget with a fully developed plan. They could have started a process of consultation and engagement that might’ve got an outcome that was sound policy and politically defensible and avoided most of the unfair features of the budget plan but also a lot of political pain.
I actually suggested at one point when it was going rough for them that perhaps they could give the Productivity Commission a reference to do that process and to leave those consultations at arm’s length from government, but that didn’t go anywhere either, except the back page of Fin Review.
As I say, taking the timing out of the budget process would have helped a lot and most of all perhaps sacking the bright spark who proposed hypothecating those savings to that medical research foundation. They had no sense of policy and they had no sense of politics and I suspect their knowledge of the healthcare sector could be written on the back of a postage stamp and I’ve named no names but you could possibly guess who I’m talking about.
In terms of the consequences of policy failure it certainly killed off the coalition’s appetite for more doing anything more than tweaking Medicare and healthcare generally. It’s emboldened Labor to make itself a populist champion of the people, blocking even minor changes such as the proposed reducing of the pathology and diagnostic imaging bulk billing incentives, and in a way it’s set Medicare in politically unbreakable concrete and, if you accepted Bill Shorten and Catherine King, the shadow health ministers’ rhetoric from the election campaign about Medicare: we will not cut Medicare – “we will not touch Medicare” – to cheaply cut a dollar from Medicare would be a breach of Labor’s election promises.
They’ve actually dug themselves in such a hole that if they ever got to implement a plan that they would be in political trouble perhaps even more diabolical than the copayment experience, but the other side of that I think is its going to, because of the Mediscare in particular, it’s going to be very hard for rational policy plans and proposals to get a fair hearing and to alter the point to get a fair run of a trial and that’s a real worry I think that we have to consider.
Again, that made the AMA the chief arbiter of what is possible and what isn’t in terms of the healthcare system and further entrenched the vested interests that strangle Australian healthcare innovation: and that is largely people in the system and those self-appointed experts who believe that they are the guardians of Medicare. The fact that somebody else has to pay for it, that basically it’s you and I, doesn’t really occur to them. The ultimate consequence, of course, is that we will continue to waste billions of taxpayer dollars that could be better spent or saved.
Peta talked about that, the waste, before. I worked in the health department many years ago I had a colleague with a screensaver: “Half of all health expenditure is wasted, the problem is we don’t know which half”. My role in this debate, while I didn’t start it, I certainly kicked it along, but I helped create an anti-reform state of affairs. For that I am truly sorry and I apologise.
In terms of implications for major healthcare reform from here, as I said the GP copayment was a relatively minor proposal in the bigger scheme of things that got blown out of proportion. It almost brought down the government and was a big factor in the downfall of a PM. In fact, I thought of calling this talk “Tony Abbott, my part in his downfall”. Yet there is no doubt the truly fundamental reform of the system such as we’ve been hearing about is needed as the Australian population ages and the whole population starts to show the acute and especially chronic consequences of our soft and namby-pamby sedentary self-indulgent and lazy lifestyles. And the sugar taxes won’t solve those problems by the way.
Let’s not forget the spiteful dysfunctional marriages of federal and state, and public and private, responsibilities for health care funding and service delivery. Our federation indeed is perhaps the biggest single drawback to meaningful healthcare reform, yet we cannot easily remake the federation and that sets the agenda whether we like it or not. In fact, I remember at the time of the GP copayment a (then) Liberal state health minister who I knew decided to blame me for his troubles also harked back to Tony Abbott’s push to have a single federal payer of public health money, saying Abbott did something like that would actually do a lot of state politicians out of a job.
Sorry Peta, but that’s the way many people at state level think, and I suppose preselection candidates would worry about.
The GP copayment and Labor’s successful Mediscare, I think, ultimately showed that the Whitlam-Hawke Medicare settlement is not easily tampered with. The Australian public won’t readily tolerate even minor change to that settlement, let alone major renovation, and that’s because of the politics around it. The grounds for such changes therefore need to be well-tilled, and in the populist rent seeking mentality that now dominates our politics, this requires real political courage that I think is sadly lacking.
Indeed, I fear genuine big thinking by genuine big thinkers, such as referred to tonight, it scares politicians and government and provides easy targets to the oppositionists and populists who dominate federal and state agendas these days. And by opposition I don’t just mean Shorten Labor: I mean any party or leader seeking to gain office by playing to the fears of voters rather than to the aspirations. Indeed, when vote-hungry oppositions shred a government’s record on obsolete measures like bulk billing rates, public hospital beds and waiting times and pander too much to the wishes of doctors, that is the AMA, rather than the best interests of patients and taxpayers, we get reform paralysis not a climate of innovation.
So aligning reform aspirations to community aspirations and expectations therefore is a big challenge for genuine health policy thinkers and reformers. The first big step is understanding those aspirations and expectations and making the fundamental change evolutionary rather than revolutionary and I also think it needs to ask as we go through this policy to answer some pretty tough questions and make some challenging conclusions. So, despite the failure of the copayment, essentially plugging away at the Australian community’s entrenched mindset about Medicare and healthcare provision.
Medicare is a healthcare access scheme. It is not a middle-class welfare entitlement scheme as politicians, particularly those are on the left of politics, condition us to think. The better-off should not expect bulk billing, and all this should not assume that health services are an ever-running bottomlessly funded tap.
I think we also need start asking ourselves some very difficult social and ethical questions about what services are provided and paid for by taxpayers including people who voluntarily assume risks that damage or destroy good health. Smokers for instance shouldn’t expect to be top of the queue for expensive treatment arising from the habit. People who attend emergency departments be patched up after alcohol-fuelled brawls should not expect free treatment. People who contract type II diabetes because of the lifestyle choices shouldn’t expect everyone to pick up the full tab for their own improvements, and private health insurance should at least have some element of risk rating, including positive rewards for those doing the right thing by themselves and by others – and that includes taking steps to do the right things.
And as medical science gets better and better at keeping people going, is there such a thing as providing too much healthcare? There are too many people with chronic conditions, in my view, particularly the very old who are kept going but whose quality of life is reduced or perhaps even almost non-existent. We do need I think to have a conversation about the right balance between keeping people alive when lives become miserable, and people and families perhaps should not expect the taxpayer should keep stringing things out indefinitely.
But, on the other hand, I think perhaps we as a community need to change our own mindsets and own expectations about what’s right, particularly as we reach the end of our lives. We can’t go forever. And in areas like IVF with the physical and emotional cost on patients is terribly high the chances of successful outcomes depressingly low incorporate imperatives actually manipulate demand. It’s arguable that treatment subsidies should be strictly limited if they are to be applied at all.
And I also think that preventing and mitigating illness and injury should be greater part of the healthcare service delivery and funding picture provided that it involved genuine harm reduction based on people taking responsibility for themselves. I’ve taken a bit of policy interest in vaping, quitting smoking and getting people off the deadly weed, because according to the emerging body of evidence some say it’s at least 95 per cent safer than smoking.
Yet Australian regulation virtually suppresses it if it involves nicotine. The thing is, when the Australian public healthcare establishment prefers to keep things as they would like them to be as opposed to accepting the possibility of disruptive innovation actually leading to genuine improvement in health outcomes we have a real problem. But when we also have a situation where our politicians as funders and regulators of the healthcare system are too afraid to do anything that challenges the status quo the challenges received wisdom and aren’t prepared to go elsewhere for advice and guidance we going to get nowhere. We’re talking right across the board, but I just think in the public-health space it is really a problem.
To wrap up, these are tough emotional confronting conversations but they need to be had, I believe they must be had. A genuine climate of healthcare reform can’t be created if questions like these are set aside. They help create a definition of what is possible, but I think the point of all this is that sadly our political class is not up to providing a courageous thought leadership that makes innovative reform possible.
Peta talked about inoculating the public, I think it’s the other way around. We should be inoculating our political leaders to feel that they can take on the populists and the opportunists and actually do something courageous and actually set us on the road to a better healthcare system, better healthcare outcomes, and a more efficient use of taxpayers money.
Terry Barnes is a former senior adviser to Howard government health ministers, and is a part-time fellow of the UK Institute of Economic Affairs. This is a transcript of a speech given at the CIS last Wednesday.
Update: Youtube clip of event.