Outside a small retirement unit in Geelong, former gardener Gerard Nicholls is forced to sit on a stool just to prune his rose bushes.
The 71-year-old needs a double hip replacement — and he's been waiting two years for the elective surgery in Victoria's COVID-stretched public hospital system.
"To walk, I'm limited down to about 100 metres [and] driving a car can be painful," he said.
"Even sitting here now, I'm in pain."
Repeated lockdowns and elective surgery bans during the pandemic have extended his wait and, years on, he still has no date for his procedure.
For Gordon Clutterham, 69, the situation is very different.
The keen cyclist from Zetland in Sydney had been struggling with mobility for years after osteoarthritis eroded both of his knee joints.
Over the past six months, he has had both knees replaced — the second within weeks of diagnosis.
Proudly showing off the 30-centimetre-long scars on both his legs, he said he hoped it would only be a short time until he was back on his bike.
"The thing I've missed most is cycling," he said.
Neither of the men had private health insurance.
But Mr Clutterham got his procedure far sooner than Mr Nicholls.
He is one of a growing number of Australians self-funding elective surgeries.
All up, the surgery at Sydney's Royal Prince Alfred public hospital cost about $8,000 for each knee. Once Medicare rebates were subtracted, he estimates he was out of pocket about $6,000 for each procedure.
Self-funding — the ins and outs
Mr Clutterham was treated as a private patient in a public hospital.
In doing so, he bypassed a queue of more than 95,000 people waiting for public surgery in NSW.
"You can get on the public list and wait six to 12 months or, if you're able to pay for yourself, it will be six to 12 weeks," he said.
"I don't want to push anyone else further down the list, but my impression is there isn't a list. There are multiple lists."
In a statement, a NSW Health spokesman said elective surgery schedules were based on clinical urgency assigned by the treating doctor.
"The payment type — public, private or self-funded — does not make a difference," they said.
Health consumer advocates say many other patients are choosing to self-fund within the private hospital system as well, with elective surgery bans during lockdowns in some states pushing out waiting lists.
Consumers Health Forum of Australia chief executive Leanne Wells said a survey of more than 100 health consumers found nearly one in four had either self-financed a procedure or knew someone who had.
In 80 per cent of cases, patients had used their savings to pay for the procedure and almost all were urgent or major surgeries.
"It's starting to emerge as a sort of reasonably attractive option," Ms Wells said.
"There's an increasing appetite because people are continuing to see the poor value of private health insurance."
But she said some patients were going to extremes to fund procedures, including drawing down on their superannuation.
"Others are drawing on savings, others may take out loans, others look at [pay-later] arrangements," she said.
"Others look at instalment arrangements with [hospitals] and others are seeking out providers [such as hospitals, clinics and specialists] who are offering a bundled set of treatment for a fixed price."
The numbers and the risks
Health economist Rosalie Viney from the Centre for Health Economics Research and Evaluation said for some patients, self-funding made economic sense.
"If we take typical private health insurance for a family, it might be around $700 a month, or nearly $8,500 a year," she said.
"If you put it aside, that would mean that you probably have the money available to pay for the procedures."
They had to weigh that against the tax implications for each family or individual who may be hit with penalties for not having health insurance.
But Rachel David from Private Healthcare Australia, which represents health insurers, warned the practice came with risks.
"It is not a suitable model for anyone with a chronic illness or anyone that might need expensive follow-up care as a result of likely complications of surgery," she said.
"The other problem is, a lot of people really underestimate the costs of surgery."
Public and private systems need federal injection
Both sides of politics are under pressure to do more for health and cost-of-living expenses like health insurance premiums.
The national median wait time for surgery has blown out by 10 days, with the worst waits for cataract, ear and nose procedures along with hip and knee replacements.
In Tasmania, 59,000 people are waiting just for an appointment with a specialist — the step before they end up on the waiting list.
State governments manage public hospital waiting lists and they have called for the federal government to increase its share of public hospital funding from 45 per cent to 50 per cent to deal with pandemic-related backlogs.
In a statement, a spokesperson for Federal Health Minister Greg Hunt said the Commonwealth currently contributes more than 60 per cent of the total government health funding across Medicare, hospitals and mental health.
They said the Coalition's suite of private health insurance reforms had contributed to record levels of membership, and its changes to medical device pricing would add $900 million to the sector and put downward pressure on premiums.
In 2022, the Coalition approved a premium rise of 2.7 per cent, which was the lowest since 2001, although many attributed this low increase to the lack of private hospital usage during the pandemic.
Labor did not respond to ABC inquiries.
A Victorian government spokesman said it had a $1.5 billion COVID-19 catch-up plan which included an extra 40,000 elective surgeries by 2024 and that 99.6 per cent of the most urgent elective patients were seen within 30 days in 2021.
The NSW Health spokesperson said it had spent more than half a billion dollars over the past two years to fast-track elective surgeries and said any patient who felt their condition had deteriorated while on a waiting list should contact their treating doctor for a review.
"To reduce waiting lists, NSW Health is increasing internal surgery capacity, implementing new models of care in public hospitals, and working in partnership with private hospitals."
Private health does the most hips and knees
Private hospitals do nearly two-thirds of elective surgeries in Australia and increasing insurance membership could also take pressure off public lists.
In Victoria, the state government has effectively taken over Frankston Private Hospital to help remove some of the 80,000 patients on its waiting list.
But Rachel David from Private Healthcare Australia said the key issue for insurers was the affordability of premiums.
Costs have been rising by about 4.5 per cent on average each year for the past decade, which was well above inflation.
Suggestions include increasing government subsidies for premiums, shortening private hospital stays and fixed or bundled prices for set procedures to force hospitals to drive costs down.
Professor Viney said the private health sector also needed to control its own admin costs.
As well, there needed to be some accountability for insurers, who continued to seek federal government approval for large annual premium rises despite making significant profits.
"We need to look at what is the average claim for that insurer and the amount of payout for the amount of premium they've received," Professor Viney said.
The Consumers Health Forum of Australia said there should be an independent Productivity Commission review to cut through lobbying from vested interests.
Mr Clutterham is the first to admit patients should not be forced into the situation he confronted and he was fortunate he had the money to pay.
"Australia should be able to allocate health resources on the basis of need."
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