When Dr Brian Morton became a trainee general practitioner in 1977, healthcare bills were the No 1 cause of personal bankruptcies in Australia.
On more than one occasion Morton provided treatment to patients who couldn’t afford to pay. “If someone turned up, you wouldn’t turn them away,” he says.
Access to treatment in hospital was dependent on having private health insurance or being able to afford paying out of pocket.
Those unable to pay for treatments like joint replacements were left with little choice,” Morton recalls. “People with knee arthritis or hip arthritis just had to live with it and deal with the pain and the disability.”
Life expectancy was lower, and people often died in their late 60s and early 70s without having received the care they needed.
Even those with private health insurance could find themselves only covered for a certain number of days in hospital and found it ran out during their stay.
That all shifted when universal health insurance services – now known as Medicare – were introduced in 1984.
“Medicare was a dramatic change in terms of rebate subsidies for everyone, but especially those who were finding it difficult and also families bringing their children,” Morton says. “There was a massive change in the access to general practice.”
It wasn’t without controversy – as Neal Blewett, the health minister when the universal health insurance was introduced under Bob Hawke, admitted this past weekend, even the government of the day did not expect Medicare to last 40 years.
As Medicare marks its 40th anniversary on Thursday, health experts say it’s a time to reflect on whether Australia’s “little green card” is meeting all its goals.
A program fought ‘tooth and nail’
Medicare’s first iteration, Medibank, was introduced by the Whitlam government in 1975 but enjoyed only a short period of operation before the government was dismissed.
The incoming Fraser government modified Medibank, including changes to agreements with the states over how much money hospitals would receive, restrictions in benefits and bulk billing, and rebates for those with private insurance.
Those changes were largely revoked by the incoming Hawke Labor government in 1984. Then, on 1 February, Medicare services began.
The current health minister, Mark Butler, reflects that the program was “fought tooth and nail” – by the Liberal and National parties led by John Howard, as well as doctors’ groups who were at first concerned it would lead to similar struggles as the UK’s National Health Service.
“Universal health insurance was perhaps the most defining fault line in national politics in this country … right until the early-to-mid-1990s, when the Liberal party finally dropped its formal commitment to abolish Medibank and Medicare in their entirety,” Butler says.
Dr Elizabeth Deveny, the chief executive of the Consumers Health Forum, says Australians “love their little green card” but they often only realise Medicare is paying for something when they hand it out to someone, most often at the GP.
“I suspect Australians don’t realise how lucky they are in having a healthcare system that’s not only universal but also portable throughout the whole country,” Deveny says.
A time to reflect
The president of the Australian Medical Association, Prof Steve Robson, says like all “big birthdays”, Medicare’s 40th anniversary is a time to pause and reflect on its future trajectory, and whether it is achieving its goals.
“The health landscape is very, very different now to the way that it was – not only 40 years ago – but you’ve got to remember that the architecture of Medicare was really built 50 years ago,” he says.
Australia’s population now is much older than it was 50 years ago and some of the most prevalent conditions needing treatment are chronic diseases and mental health which need multidisciplinary ongoing care, Robson says.
“And Medicare really wasn’t designed for that. It was designed for episodes of care – where if you had a gallbladder problem, you would see a doctor, have it dealt with and go home.”
Robson says the next advance for the scheme needs to be building multidisciplinary teams to manage chronic diseases. Australians with diabetes, for example, require diabetes educators, nurses, specialist care from an endocrinologist as well as possibly an exercise physiologist.
“We don’t want patients having to drive all over the place,” Robson says. “Putting teams together in one place and deliver for diabetes is one example of where the future has to be …
“There is a lot of work to be done. Large government programs are like aircraft carriers – they take a long time to turn around.”
Deveny agrees the main challenge facing Medicare is adapting in the face of the increasing burden of chronic disease.
“Right now, the universality of Medicare is under threat,” she says. “The Consumer Health Forum is concerned by some of the commentary that has emerged in the sector over the last few years, which is viewing Medicare as a safety net for the most disadvantaged, and not as a universal access scheme for all.”
Deveny says there are now large out-of-pocket costs, meaning that the system isn’t offering universal free healthcare any more.
“Now it’s – there’s some free care, but the rest you’ve got to be able to pay – and this is why we hear so much from health consumers that they can’t afford the healthcare, and they make the decisions not to get care.”
Deveny says GPs who have worked in the system for more than 40 years say Medicare came as a “huge relief” as they no longer had to decide whether to charge a patient who is struggling financially.
The dilemma from the past is now facing GPs again, she says.
“How do they help people stay well, which is their primary concern, but also look after their own business, their own health and their staff?” Deveny says.
“We believe that universal healthcare is important and those who believe that it is should take note of this and not let our current system be eroded.”
