The 'Boomer Bulge': Ageing Policies for the 21st Century


Research Paper 4 1998-99

Greg McIntosh
Social Policy Group
24 November 1998

Contents

Major Issues Summary

Introduction

The Demographic Imperative

The Current Provision of Services/Support for the Aged

Commonwealth Funding For The Aged

Some Policy Options

The Overseas Experience: Some Examples

Conclusion

Endnotes

Select Bibliography

Major Issues Summary

Australia's population is ageing and unless some policy adjustments (especially with regard to the provision and funding by government of pensions and health and long-term care) are made there is likely to be a degree of dislocation and hardship experienced by segments of our society.

It should be emphasised, though, that the rate of ageing of the population is occurring relatively slowly over a long period of time (it is predicted that the proportion of the population aged over 65 will increase from 12 per cent in 1997 to approximately 25 per cent in 2051) and the effects of this ageing phenomenon are not likely to be as adverse as some of the doomsayers would suggest. Some countries are already more 'aged' than Australia will be in 15 to 20 years time and these countries have not thus far experienced significant adjustment problems. Nevertheless, unless some adjustments are made in the near term, then it is likely that much more difficult and painful decisions will have to made in the longer term. Appropriate policy adjustments now will enable long lead times for these policies to be implemented and the 'cost' of such policies will be able to be spread over a much greater time period and over successive generations.

A common feature of many of the world's developing countries, in response to the ageing process, is the progressive implementation of policies designed to reduce the level of government funded age benefits as well as extending upwards the age eligibility at which many of the benefits can be accessed.

Many of the services and support that exist for the elderly in Australia were developed when life expectancy was much shorter and when many people died within a relatively short period of time after becoming eligible for payments such as the Age Pension. Now many elderly people live well into their 80s and beyond and, as a consequence of this, the cost of government funded age support is rising rapidly. For example, outlays on the Age Pension are predicted to rise from $13.4 billion in 1997-1998 to $16.5 billion in 2001-2002. Rapid economic growth, and a buoyant world economy, would help sustain such outlays; but such favourable economic conditions are rarely experienced for more than short periods of time. Prudent policy making would suggest the need for policy adjustments that take account of changing demographics and future economic downturns.

Of critical importance is the need for policies related to aged care to be considered holistically and with the longer term in mind. Often additional spending in one area (for example, in home and community care and fitness programs) will mean less need for spending in other areas (for example, hospital funding) in the future, or, may at least delay the need for such funding to a later time. Governments and policy makers with a short term budgetary view to policy may 'save' money in the short term but cause additional and unnecessary expenditure in the future.

Some possible policy options to respond to the ageing of the population include:

  • active encouragement being given for people to remain in the workforce for longer periods of time
  • better superannuation and retirement incentives. Australia is unique in that superannuation contributions are taxed concessionly at all three levels of the contribution cycle. The emphasis for superannuation (apart from making it less complex) should be on strong incentives for workers to provide for their own retirement and for them to take their superannuation as an 'income stream' as opposed to a lump sum. Additionally, the current restrictions that essentially prohibit people aged over 70 contributing to superannuation should be lifted
  • the existing Pension Bonus Scheme (that allows people to defer the age at which they receive the pension if they stay in the workforce, in return for a cash bonus on retirement) could be expanded and made more attractive
  • additional employment opportunities for the elderly. Over the period 1973 to 1993 full-time labour force participation by males aged 55 to 64 years declined from 79 per cent to 52 per cent. If this participation rate can be lifted the call on government revenue will be reduced accordingly. Overseas programs such as the Euro Work Age program could be studied and adapted to Australia's circumstances
  • specific levies and long-term care payments could be considered. One proposal put forward recently by a group of researchers at the University of Western Sydney (the so called Ensuring Quality of Later Life or EQOLL model) advocated that all people aged over 25 years, with an income in excess of $15 000 per annum, should pay 1.1 per cent of their income over the period 2000 to 2011 in one of four ways to help cover the costs of long-term care. The four options would include: 1.1 per cent of taxable income paid as a supplementary levy and added to the existing Medicare levy; 1.1 per cent of taxable income paid to an approved life insurance fund; 1.1 per cent of income paid to an appropriate aged care insurance fund or 1.1 per cent of income paid into Continuing Care Retirement Communities
  • tighter targeting of income support. Consideration could be given to tightening the existing income and assets as they apply to Age and Service Pensions
  • constraining the growth in health outlays. Expenditure on health services does tend to increase as people age. For example, in 1993-94, 35 per cent of total health system expenditure was spent on people aged 65 years and over, while this group comprises less than 12 per cent of the population. As well as examining a range of financing options for health care in the long-term it is also important that a debate be initiated on just what Australia's health system can realistically be expected to provide in the future. In order to ensure that sufficient funding is available to provide equitable access to adequate health services and treatment, it is important that a dialogue be commenced on the priorities for the allocation of resources for health care
  • a range of other more minor initiatives such as the establishment of 'one stop shops' for the elderly to give seamless advice on ageing and retirement issues and additional resources geared to encourage volunteerism, active ageing and the like.

The current Commonwealth Government's main long-term policy response to the issue of an ageing population has been the establishment of the National Strategy for an Ageing Australia. The Strategy includes provision for a wide range of consultations with all levels of government and the community and private sectors. A number of discussion papers looking at the host of issues involved with an ageing population are to be released over time as part of the Strategy. The Strategy would appear to be an appropriate vehicle for the Government to use when it is examining issues related to ageing. However, it is important that the momentum that the early phases of the Strategy is likely to generate (particularly given that 1999 is International Year of Older Persons) is not lost and that the Strategy is given adequate resourcing well into the future so that it has the 'horsepower' to do what it is intended to do.

Introduction

Australia, in common with other developed nations, is experiencing an ageing of the population. This ageing phenomenon is predicted to continue, to varying degrees, well into the next century. For example, Australian Bureau of Statistics (ABS) projections(1) indicate that the proportion of the population aged over 65 years of age will increase from 12 per cent in 1997 to between 24 per cent and 26 per cent by 2051. The median age of the population is predicted to rise from 34 years in 1997 to 40-41 years in 2021 and 44-46 in 2051. According to the ABS, the highest rates of growth in the plus 65 years age group will occur when the peak of the 'baby boomers' (generally considered to be those born post war, i.e. from 1945 to the early 1960s) enters that age cohort. This is expected to happen during the second and third decades of the next century.

On the face of it, this ageing of the population points to a society with a shrinking proportion of the population in the workforce having to increasingly bear the burden of supporting a growing proportion of older non-employed people. However, opinions vary as to just what the effects of ageing will be with some commentators predicting dire consequences in terms of the costs of ageing whilst others argue that the purported 'downside' effects are overstated, pointing to the fact that some overseas countries have 'aged' to a far greater extent than Australia has thus far without any apparent social/economic dislocation. In reality, there are many factors in the future (for example, rates of economic and productivity growth, the size of the 'young' population, rates and effects of technological change, levels of immigration, changing behaviour patterns and government policy settings) that are impossible to predict accurately, so much of the commentary can only be viewed as informed speculation. Having said that, though, there would appear to be no doubt that the ageing process will have an effect on our society particularly in areas such as health provision, social security, housing and retirement income provision.

Because this ageing trend raises many important issues for policy makers, and also because 1999 has been designated as the International Year of Older Persons, it is timely that an examination of some of these issues is undertaken. The aim of this paper is to give an overview of demographic trends as they relate to ageing, as well as look to some of the possible policy responses that may be considered appropriate as a result of these trends. The paper also outlines the current provision of services and support for older Australians as well as briefly examining what is happening in relevant overseas jurisdictions.

 

The Demographic Imperative

A Brief Profile of the Australian Population

The 1996 Census counted 17 892 423 people in Australia on census night. Of this total, 50.5 per cent of people were female and 49.5 per cent were male. As well:

  • the median age of the population was 34 years of age
  • 21.6 per cent of the population were aged between 0 and 14 years
  • 14.5 per cent were aged between 15 and 24 years
  • 30.8 per cent were aged between 25 and 44 years
  • 21 per cent were aged between 45 to 64 years
  • 12.1 per cent were aged over 65
  • the highest median age was in South Australia (35 years) whilst the lowest median age was 29 years in the Northern Territory.(2)

The vast majority of the population (73.9 per cent) were born in Australia and, of those born overseas, 36.2 per cent were born in the United Kingdom, Ireland and New Zealand. A total of 352 970 people identified themselves as being of Indigenous origin, with 55.8 per cent of these people living in New South Wales and Queensland.(3) The importance of immigration to the development and growth of Australia's population is illustrated by the fact that over the period 1985-1995 there was a net overseas migration gain of 979 000 people, accounting for approximately 43 per cent of the total population growth over that time.(4)

The Aged Population in Australia

The usual measure of just how aged a population is (the proportion of the population aged over 65 years of age) varies significantly across the eight political jurisdictions. Whilst the proportion of people aged over 65 years in 1996 was 12.1 per cent for Australia as a whole the equivalent figure for each of the States and Territories was as follows: New South Wales 12.7 per cent, Victoria 12.0 per cent, Queensland 12.0 per cent, South Australia 13.8 per cent, Western Australia 10.5 per cent, Tasmania 12.3 per cent, Northern Territory 4.9 per cent and the Australian Capital Territory 7.1 per cent.(5)

A more detailed breakdown of the aged population published by the Australian Bureau of Statistics (ABS) in 1997(6) shows the proportions of aged people in various age categories above 65 years. According to the ABS there were, in 1997, a total of 2 245 068 persons in Australia aged over 65 years of age.

Table 1 - Aged Persons, Proportion of the Total Population by Age, 1997 (per cent)

65-69

70-79

80+

Total Aged

New South Wales

3.9

6.0

2.8

12.7

Victoria

3.8

5.9

2.9

12.6

Queensland

3.5

5.3

2.5

11.2

West Australia

3.3

4.8

2.4

10.5

South Australia

4.1

6.7

3.3

14.1

Tasmania

3.9

6.1

3.0

12.9

A.C.T.

2.5

3.6

1.4

7.4

Northern Territory

1.4

1.4

0.5

3.3

Australia

3.7

5.7

2.7

12.1

Source: Adapted from ABS, Population by Age and Sex, Catalogue No. 3201.0.

Table 1 clearly shows that the two Territories had by far the smallest proportion of their populations in the aged categories, whilst of the States, South Australia had the highest. For policy makers the age group of particular relevance is the 80+ group as it is from this cohort that the most demand for services and assistance comes. As the table shows, only 2.7 per cent of the population were in this latter category in 1997. However, the Economic Planning and Advisory Commission (EPAC)(7) has estimated that the proportion of the population aged over 80 years of age will be between 7 to 8 per cent by 2051.

The Ageing Trend

Arguably, the most significant demographic trend is the ageing of the Australian population. If one looks at changes over a relatively long period and also at the various projections on ageing into the next century it can be seen that issues and policies related to the aged in Australia will become increasingly important over the next 30 to 40 years.

The 1991 Census counted 16 852 258 people which means that there was a 6.2 per cent increase in the population over the period 1991 to 1996. The median age of the population in 1991 was 32 compared to 34 in 1996, an increase that confirms the ageing trend.(8)

Between 1985 and 1994 the population aged 65 and over increased by 30 per cent whilst at the same time the increase for the whole population was only 13 per cent. In terms of the States and Territories over the same period the greatest increases in the aged sectors of the population were in the ACT (65 per cent), the Northern Territory (55 per cent) and Queensland (38 per cent).(9)

Since 1985 the greatest rate of 'ageing' has occurred in the over 80 years age group. Between 1985 and 1994 the size of the 80+ age group increased by 48.4 per cent compared to 25.7 per cent for the 70-79 age group and 26.3 per cent in the 65-69 age group. Over the same period there has been an increase in the proportion of males in the aged population compared with females, although in absolute terms there are still more 'aged' females than males.(10)

Australian Demographic Trends 1997(11) describes the ageing trend as follows:

During the late 1980s and early 1990s the population aged 65 and over grew at around 50,000 people per year. In the next decade this rate of increase will fall to between 35,000 and 50,000, as the relatively small cohorts born in the depression enter the age group. However, after 2008, the growth in this age group will increase rapidly. In one 12 month period of 2025-26, the population aged 65 years and over is projected to increase by 120,000, or 2.7 per cent. In the decade to 2028, the population aged 65 years and over is projected to increase by more than a million people, nearly a 30 per cent increase. This represents the period when the largest group of baby boomers reach retirement age. During the early 2020s, the numbers of children in the population is projected to fall below the number of people aged 65 and over.

The Economic Planning Advisory Commission (EPAC) Study

A major study on the effects of ageing was done by EPAC(12) in the mid 1990s. Some of the important trends and issues raised in this study included that:

  • the dependency ratio (the ratio of the young and the old to those in the workforce) is predicted to rise from 50 per 100 people at present to 60 or more by the year 2051. Increasing the rate of net migration would only have a marginal effect in terms of helping slow the growth rate of the dependency ratio and the most appropriate way of dealing with an ageing population is via a range of social policies
  • at present approximately 19 per cent of GDP ($64 billion) is spent on government social programs. This is expected to increase substantially with the ageing of the population There will be some 'freeing' up of resources due to a decline in young-age dependency but this will be more than countered by the ageing effect. Ageing of the population will also place some pressures on the tax base but this may be at least partly offset by policies such as later retirement and increasing the rate of superannuation accumulation for those currently in the labour force
  • total expenditure on education is projected to decline as a proportion of GDP because of the smaller proportion of young people in the population. However, this may be largely offset by the increased educational demands of the mature aged
  • according to one projection the total cost of health care expenditure could increase from approximately 8.1 per cent of GDP at present to 11.1 per cent in 2051. This could see the proportion of health care expenditure that goes to the aged increase from one-third (now) to in excess of 50 per cent in 2051.(13) Dealing with this projected increase in expenditures on health is likely to require control of the level of expenditure rather than just changes to administrative procedures. It is likely that there will be a need to more directly face the issue of health rationing
  • as the ageing process increases over time the proportion of the population with a disability or disabilities is projected to increase from 10 per cent to 15 per cent. This is significant because this group of the population is likely to require intensive, high cost support
  • changing demographic and social conditions (for example, more women in the workforce and people working longer) are likely to limit the number of carers available to help the aged and infirm
  • as the number of people entering residential aged care establishments increases there is likely to be a consequent increase in aged housing expenditure
  • changes in society over the next 50 to 60 years are likely to see major shifts in the obligations and roles for the old, the young, those in the workforce and those that are retired.

The Worldwide Ageing Trend

The ageing trend that Australia is experiencing is common to the rest of the developed world. In fact many developed countries are much further down the ageing path and, given that most of these countries have 'aged' without dramatic economic and social upheaval, Australia should be able to manage the ageing process without too much dislocation and hardship. The degree of ageing and the differences between countries with respect to the rate of ageing is indicated by the following statistics. In 1950 approximately 8 per cent to 9 per cent of all people in America, Europe, Australia and New Zealand were aged over 65 years of age. By 1993 the percentage of the population aged over 65 was 18 per cent in Sweden, 16 per cent in Norway and Denmark, 13 per cent in the USA and 12 per cent in Australia and New Zealand.(14)

In terms of future growth rates, however, Australia is one of the countries that is expected to be experiencing a higher than average increase over the 1995-2005 period in the proportion of the population aged over 65. According to the Australian Institute of Health and Welfare:

Japan and China lead the field with annual average rates of increase around 3%, followed by Australia, Canada and Germany (1.7-1.8%), with virtually all the other remaining countries at less than 1%. The rate of growth in the population aged 80 and over is quite high for Australia at 3.9%, similar to that for both Japan and China. Canada, too, can expect a fairly rapid growth in this age group, with a 3% predicted rate of increase over the 10 years to 2005.(15)

The urgency with which the international community should address the various issues related to ageing is highlighted by the Organisation for Economic Co-Operation and Development (OECD). According to the OECD action is needed now and that:

Successful reforms will bring large rewards. They would avoid major fiscal problems, improve living standards and the quality of life, and result in a more equitable, cohesive society. The temptation to delay action is strong, but the message that the OECD seeks to communicate as widely as possible on behalf of its Member governments is that solutions will be much more difficult and painful if needed reforms are postponed...Responding to these challenges requires action on many fronts. Spending on public pensions, health and long-term care must be contained. The structure of retirement income must be reformed and incentives to early retirement eliminated. There must be more support for people as they grow older, to play a productive life in the labour market and society. Financial market reforms are required in response to the huge growth in pension funds. Reforms that result in higher economic growth would alleviate the pressures of ageing.(16)

Differing Interpretations of the Ageing Trend in Australia

There are differing views within Australia on the effects and consequences of ageing and just what is needed to be done to prepare Australia for the future. For example, the National Commission of Audit painted a fairly bleak picture whilst Fred Argy, a former senior Commonwealth public servant and respected economic commentator, is more optimistic. The 1996 National Commission of Audit(17) recommended that:

  • The Government should urgently implement measures to reduce the potential for longer term age related funding increases, or failing that, make allowances now in budget figuring to provide for them.
  • The Government should take action now to change expectations of reliance on government assistance, by reducing aged and health related outlays. Suggested measures include:
  • while maintaining universal access to nursing homes for those in need, change funding arrangements so that those able to contribute more towards their own care do so. This could be achieved by introducing means testing for nursing home benefits and, for income poor but asset rich clients, providing scope for the Government to recover the cost of nursing home benefits from their estates
  • investigating the potential for financial institutions to offer cover against age related long-term care requirements along the lines of a life policy to encourage those able to contribute to their care to do so.
  • The multiplicity of benefits for assisting with the cost of raising children should be reviewed for consistency.
  • The Government should comprehensively review the impact of current tax and social security arrangements on the incentives for household saving. This review should examine options for improving the contribution of household saving to Australia's national saving effort, including, if necessary, changes to the proposed superannuation co-contributions policy.(18)

Conversely, Fred Argy maintains that the National Commission of Audit has overstated the potential problems arising from the ageing process. According to Argy:

An immediate point to note is that the age hump in the population only starts to show up in Australia about 15 years from now and then extends for 30 to 40 years after that. Between now and 2015, private saving seems set to increase substantially because it is the peak saving period for baby boomers.

That aside, the future demands on government associated with increased dependency ratios have tended to be exaggerated .

First, projections far into the future are very uncertain because of unpredictable changes in technology and social preferences. Let me illustrate. The NCA [National Commission of Audit] has estimated that public expenditures on health will increase from about 9 per cent to 16 per cent of GDP by the year 2031.(19)

The Economic Planning Advisory Council projected an increase of only 11 per cent. And the Australian Institute of Health and Welfare foresees a decline in health expenditures relative to GDP in this period (although these latter projections have been questioned). Where the estimates differ is in the assumptions they make about growth in (a) GDP per capita growth and (b) per capita increases in health expenditure.

Second, projections of age dependency are usually based on very conservative estimates of labour participation rates. Yet the prospect of fewer school leavers and a tighter labour market after 2010, and the improved health and life expectancy for older Australians are both likely of themselves to induce further increases in labour force participation.

Third, the changing age composition of the population will produce offsetting declines in other areas of public expenditures such as education and will almost certainly mean lower unemployment benefits (because of fewer school leavers looking for work).

Fourth, dependency ratios are very amenable to policy correction. For example, social security policy will not remain static between now and then. There could be changes in the official retirement age for pensioners, further incentives for pensioners to postpone retirement, increases in the preservation age or restrictions on lump-sum payments (to ensure the superannuation benefits are not frittered away before they reach pensionable age).

Alternatively, we could see provision for compulsory employee contributions with matching government co-contributions (not just employer contributions), changes in means test provisions; and so on.

Finally, there seems to be every likelihood that in the period 2010 to 2065 when the ageing of the population will occur, Australians will be much better off than we are now, and high dependency ratios may well be affordable...(20)

It is obvious that there is no consensus on just how 'difficult' will be the adjustments in social and economic terms that will need to be made as we move towards a more aged society. However, it would be irresponsible and naive to ignore the possible impacts of the effects of ageing. Accordingly, it is desirable that policy challenges and options in this regard are considered. Before this is done, however, it is worth reviewing the current provision of services and support for the aged in Australia.

The Current Provision of Services/Support for the Aged

Introduction

Many of the services and support that exist for the elderly in Australia were developed when life expectancy was much shorter and when many people died within a relatively short period of time after becoming eligible for payments such as the Age Pension. Now many elderly people live well in to their 80s (and even their 90s) and, as a consequence of this, the cost of government funded age support is rising rapidly. For example, outlays on the Age Pension are predicted to rise from $13.4 billion in 1997-98 to $16.5 billion in 2001-2002.(21)

General Overview

The provision of services and assistance to the aged comes from a complex array of government programs (Commonwealth, State and local) plus services from the voluntary sector, the private for profit sector and the private not-for-profit sector as well as care and support from family and friends. By far the most important source of support and assistance (apart from the family and friends) provided to the aged comes from the government sector.

The Commonwealth Government provides the vast bulk of income security payments (including age pensions, rent assistance, disability payments), residential services including funding for nursing homes and hostels, medical and pharmaceutical benefits, public housing (with the States) via the Commonwealth-State Housing Agreement, acute care (with the States) hospital services and the Home and Community Care (with the States and local government) program specifically designed to help elderly people in their homes.

The States and Territories also provide a host of health, housing and welfare services for the aged. Apart from the services shared with the Commonwealth, for example the Home and Community Care (HACC) program and public housing, they also to varying degrees provide services such as referral and advocacy support, concessions to operators of retirement homes and other age specific forms of accommodation, support for organisations such as the Council on the Ageing, the regulation of private housing and land and the provision of some transport services.

The majority of the assistance and support provided is for that section of the aged population that needs it the most-the frail and disabled. For many aged over the age of 65 there is no need for specific assistance and with a general trend towards people living longer and being healthier for longer the main emphasis in terms of assistance and support is towards the 'older' aged, that is those over 75-80 years of age. It is generally understood that the greatest need for support and assistance is in the last two years of a person's life.

The following three tables, adapted from Australia's Welfare 1993: Services and Assistance(22) provide a summary of residential and domiciliary services available to that portion of the aged in most need of support, the frail and disabled. The tables include the source of funding and the service provider.

 

Table 2 - Residential Care Services Available for the Care of the Frail and Disabled Aged

Service Type

Funding Source Provider

Service

Nursing home/hostel care

Commonwealth/State, private, clients in homes

Private State govts

Respite care in nursing homes/ hostels

Commonwealth, Clients

Private/State govts

Regulating quality nursing homes/hostels

Commonwealth/States

Commonwealth /States

User Rights agreements nursing homes/hostels

Commonwealth

Private

Ethno-specific nursing homes/ hostels

Commonwealth

Private

Clustering strategy in nursing homes/hostels

Commonwealth

Private/States

Community Visitors Scheme: nursing homes

Commonwealth

Volunteers

Employment ATSI staff in nursing homes

Commonwealth

Private/State

special hostels for ATSI

Commonwealth

Private

Dementia programs in hostels

Commonwealth

Private

Note: ATSI = Aboriginal and Torres Strait Islander

Source: Adapted from Australian Institute of Health and Welfare, Australia's Welfare 1993: Services and Assistance, pp. 201-202.

 

 

Table 3 : Domiciliary Care Services Available for the Frail and Disabled Aged

Service Type

Funding Source

Service Provider

Home Nursing

Commonwealth, State, Private, Carers

Local, Private, Carers

Delivered meals

Commonwealth, State, Private, Informal

Private, Local, Informal

Home Help/maintenance

Commonwealth, State, Private, Informal

State, Local, Private Informal

Transport/shopping help

Commonwealth, State, Private, Informal

State, Local, Private Informal

Community/paramedical help

Commonwealth, State

State

Community Care Packages

Commonwealth, State

State, Local, Private

Carers pension

Commonwealth

Commonwealth

Domiciliary Nursing benefit

Commonwealth

Commonwealth

Home/centre based respite care

Commonwealth, State, Private, Informal

State, Local, Private Informal

Advice on aids/equipment

Commonwealth, State

State

Assistance/home modifications

Commonwealth, State

State

User Rights info re HACC

Commonwealth

State

Multipurpose centres

Commonwealth, State

State, Local, Private

Source: Adapted from Australian Institute of Health and Welfare, Australia's Welfare 1993: Services and Assistance, pp. 201-202.

 

Table 4 : Residential and/or Domiciliary Services for the Care of the Frail and Disabled Aged

Service Type

Funding Source

Service Provider

Assessments/Aged care teams

Commonwealth

State

Different language information

Commonwealth

Commonwealth

Advocacy services

Commonwealth

Private

Complaints units

Commonwealth

Commonwealth

Source: Adapted from Australian Institute of Health and Welfare, Australia's Welfare 1993: Services and Assistance, pp. 201-202.

Housing

The vast majority of Australians aged over 60 years (82 per cent) occupy private dwellings, either as an owner or purchaser and a further 11.5 per cent rent from the public or private sectors in roughly equal proportions. The remaining 6.5 per cent(23) live in hospitals, nursing homes, hostels, retirement villages and other establishments such as boarding homes, hotels and caravan parks. Thus, only a very small proportion of the population aged over 60 are in specific residential aged care establishments of the type that require large amounts of support and assistance. However, in recent years, with the tendency towards 'ageing in place' and home based care more and more older people are staying at home for longer periods with the care and support coming to them as opposed to being place in institutional care.

Public Housing

The main provision of public housing for older Australians comes via the operation of the Commonwealth-State Housing Agreement (CSHA). Approximately 6 per cent(24) of older Australians occupy public rental dwellings. Most older people in public housing moved into their dwellings in their younger or middle adult years and have stayed there into retirement. Specific funding for low income pensioner housing commenced via the CSHA in 1948. In that year the Pensioner Rental Housing Program was introduced so that additional accommodation for this group would be provided in the public sector. In the 1995-96 Federal Budget approximately $50 million was allocated for the Pensioner Rental Housing Program. In the following (1996-97) Budget this Program was rolled into a general funding category which means that there is now no separate identifiable program for pensioner housing.

Residential Aged Care (Nursing Homes/Hostels)

In March 1998(25) there were 138 971 residents in residential care facilities (formerly called nursing homes and hostels) in Australia. This equates to only about 6 per cent of the population aged 65 and over. However, as mentioned earlier even though a very small proportion of the aged population is in residential care, it is to this area of support that most of the funding goes, and particularly to the high care facilities (nursing homes) which house the most frail older people. As Table 5(26) shows, of the total of $2 984 million of Commonwealth residential care subsidies allocated in the 1998-99 Budget, $2 262 million went to high care facilities (nursing homes) and $722 million went to low care facilities (hostels). In 1997 approximately half of the nursing home beds in Australia were provided by the private for profit sector, approximately 38 per cent were provided by the private not-for-profit sector and the rest were provided by government.(27) With respect to hostels, over 90 per cent of beds are provided by the private not-for-profit sector.

Recent Commonwealth Initiatives

The Commonwealth Government announced in the context of the 1996-97 Budget that there would be major structural reforms to residential aged care. The reforms are essentially a fiscal response to the ageing of the Australian population and include an extension of the user pays system in the form of accommodation charges that will help raise the funds needed to provide adequate nursing home/hostel accommodation and upgrade existing facilities. The new arrangements mean that aged people with 'sufficient' means are expected to contribute more towards their care than was formerly the case.(28) The main features of the reforms include:

  • a single resident classification scale (i.e. doing away with the distinction between nursing homes and hostels) which is used to ascertain the amount of subsidy for each resident
  • the introduction of resident entry contributions for all residential care. This has seen accommodation charges being imposed across the sector similar to those that had previously been levied in hostels. The changes have seen the Commonwealth essentially cease capital funding for aged residential care (with the exception of $10 million that is provided for special cases such as rural and remote aged residential care) with future capital works expected to be funded by the revenue raised from the accommodation charges and from the internal funds of the residential aged care providers themselves. Special provisions apply for financially disadvantaged people who are classified as concessional residents.
  • an accreditation system emphasising quality assurance. This is aimed at ensuring that before residential care operators can become part of the new arrangements they will need to obtain certification and show that the quality of the care they provide is up to appropriate standards
  • income testing of residential care benefits for all residents. Prior to the reforms nursing home residents only paid a standard fee per day towards the cost of their care and hostel residents paid variable fees. The new system ensures that residents pay a proportion of their private income towards the cost of their residential care.

Health

The majority of health services for aged people in Australia are delivered by mainstream services such as medical practitioners and public hospitals. Older people, on average, tend to be higher users of health services. Medicare, Australia's universal health system, provides older people with equitable access to medical and hospital services at little or no cost.

The Pharmaceutical Benefits Scheme provides subsidised access to a wide range of (often quite expensive) pharmaceuticals, with a small co-payment of $3.20 per prescription for concessional cardholders, including the Pensioner Concession Card and the Commonwealth Seniors Health Card. Free pharmaceuticals are provided once the safety net of $166.40 is reached in any one calendar year. From 1 January 1999 the eligibility requirements for the Commonwealth Seniors Health Card are to be relaxed, an initiative which is estimated to benefit an additional 220 000 non-pensioners.

The Home and Community Care (HACC) program, which is jointly funded by the Commonwealth and the States and Territories, provides frail aged people with support to enable them to continue living independently in their homes for as long as possible. HACC services include home help, personal care, meals on wheels and home nursing. Fees (but not full cost recovery) are charged for HACC services.

Private health insurance premiums are community rated, which means that people cannot be charged a higher premium because they are older or chronically ill. Older single people with a taxable income of less than $35 000 per year and couples and families with a taxable income of less than $70 000 per year are eligible for the Government's private health insurance incentives which commenced on 1 July 1997. This measure is expected to cease from 1 January 1999 and be replaced by a non-means tested rebate of 30 per cent of the premium paid for private health care.

Eligible older people with hearing problems are provided with vouchers by the Commonwealth to access hearing services at either Australian Hearing Services or the participating private provider of their choice.

Social Welfare

The Australian social security system provides a minimum level of income support for people who are unable, or cannot be expected to provide for themselves. The main groupings provided with assistance are:

  • the retired
  • people with a disability or a medical condition which prevents them from working
  • the unemployed
  • people who have children in their care.

The assistance is provided in a framework designed to promote self-support through employment for those with the capacity to participate in the work force. The main forms of assistance for older people are the age pension, wife pension, the partner allowance and the mature age allowance. Unlike most other overseas social security systems (see section on the overseas experience), Australia does not have a contributory based or national insurance type system to fund payments. The contributory systems generally link entitlement to the contributions made by the individual during their working life. The funding for Government social security assistance is sourced from general revenues.

Total Budget outlays for social security in 1996-97 financial year were $40.7 billion(29) or approximately 31 per cent of total national government budget outlays. Of the $40.7 billion, $13.6 billion (33 per cent) was expended on retirement incomes.

All of the payments provided for income support are means tested. The means test is made up of both an income and assets test, with limits set at levels designed to target payment to those in most need. The levels are also designed to partially or totally preclude payments to those of substantial financial means considered able to support themselves. To qualify for the age pension a man must be aged 65 years or more (female aged 61 years as of July 1997) and have been in Australia as a legal resident for ten years or more. The claim for a pension must be made in Australia, except for those countries with an international social security agreement allowing a claim to be made overseas.

As at June 1996, 2 203 180, or 12 per cent of Australia's population of 18.4 million was aged 65 years or more. Of these, the number receiving a social security (or veterans affairs) income support payment pension was 1 764 213, or 80 per cent. Just under two-thirds (65.4 per cent) of age pension recipients receive the maximum rate of pension, with the remaining one third receiving less than the maximum rate due to the tapers that apply to the income test and the assets test. The other 438 967 (20 per cent) are self-funded retirees with income from various sources, for example, investments, employment, superannuation.

Commonwealth Funding For The Aged

As mentioned earlier it is difficult to obtain a full picture of what the Commonwealth outlays on aged care are because much of this funding is incorporated into mainstream programs such as health. The main identifiable items of expenditure are age pensions and allowances, residential care subsidies for residents in nursing homes and hostels and the Home and Community Care (HACC) program. Table 5 shows that the Commonwealth, in the 1998-99 Budget, allocated over $18.4 billion for aged care in these areas.

Table 5: Commonwealth Expenditure on Age Pensions and Aged Care

Item

1995-96

(Actual)

1997-98

(Est.)

1998-99

(Budget)

1999-00

(Est.)

 

$M

%

$M

$M

$M

Age Pensions and Allowances, and Partner Allowance

12 441.0

79.8

13 617.8

14 413.4

14 993.3

Residential Care Subsidies: Low Care Needs (Previously Hostels)

527.8

3.4

694.1

722.5

757.6

Subsidies: High Care Needs (Previously Nursing Homes)

2 064.5

13.2

2 238.0

2 261.7

2 309.6

Home and Community Based Provisions (a)

564.1

3.6

851.6

1 018.1

1 086.4

TOTAL (A)

15 597.4

100.0

17 401.5

18 415.7

19 146.9

TOTAL COMMONWEALTH OUTLAYS (B)

126 705.2

12.3 (b)

136 613.4

141 570.3

146 565.9

Note: (a) Percentage of total expenditure on Home and Community Care and Community Aged Care Packages; Nursing Care for Veterans and Dependants; and Home Nursing Service. (b)Aged pension and aged care (A) as a percentage of total Commonwealth outlays (B)

Source: Compiled from Commonwealth Budget Papers by Michael Fine in SPRC Newsletter, June 1998, p. 7.

 

Some Policy Options

A Strategic Long-term Approach

The transition to a situation where there may be more old people than young people in our population will necessarily entail a 'resources' switch towards the provision of goods and services for the over 65s. There will also be a need for more flexibility across a range of areas, for example, work practices, welfare provision and how the education and health systems are structured. Of crucial importance is the need for policies related to aged care to be considered holistically and with the longer term in mind. Often, additional spending in one area (for example, home and community care and fitness programs) will mean less spending in other areas (for example, hospital and nursing home care) in the future. Governments and policy makers with a short term (say one or two year) budgetary view to policy may 'save' money in the short term but cause additional and unnecessary expenditure in the future. Such 'short termism' should be avoided but, given the current three year (often less) term of federal parliaments and the cumbersome federal system, this may be difficult to achieve in practice.

The peak body representing elderly people in Australia, the Council on the Ageing (COTA), has for some time been calling for such an approach According to COTA:

We consider that the Government should look beyond the present Budget to the longer term. A little money spent on a proper forward planning process now will bear fruit for the Commonwealth's fiscal position in years to come. Such long-term strategic planning is standard business practice. It is crucial that the Government should look to the future and commit resources for the needs of an ageing Australia.(30)

Later Retirement/Incentives to Work for the Elderly?

In recent years, and particularly since the early 1980s, there has been an increase in early retirement (leaving the workforce prior to reaching the age of eligibility for the age pension) in Australia. In 1994(31) it was estimated that 74 per cent of men and 87 per cent of women had already retired in the five year period before they were eligible for the old age pension. Consideration could be given to introducing a statutory retirement age but this would be, in all likelihood, a very unpopular move and thus it is preferable to provide a range of incentives to encourage people to stay in the workforce longer. There is a widespread perception that heading down this path will 'take jobs away' from younger people but according to one source 'there is no research which substantiates this substitution factor.'(32)

Policies designed to encourage working longer would help to reduce the call on the public purse and would fit in well with a general emphasis on 'active ageing'. Many workers in their fifties may like to 'semi-retire' rather than retire but are precluded from doing this by inflexible workplace practices which are geared to retirement or full-time work, with no option in between. Job sharing and part-time work should be strongly encouraged and promoted as should policies such as working from home which, for many workers, may see them stay in work for longer periods. Other policies such as 48/52 (where workers can 'purchase' extra leave over and above the usual 4 weeks per annum) and sabbaticals (where workers can have extra time off over and above normal leave entitlements, as is commonly available in academia) are already being pursued, albeit in a very limited way, and could be extended through the whole workforce. Obviously many of these policies would entail workers getting slightly less remuneration for periods of time but it should see at least a proportion of workers staying longer in the workforce.

Superannuation/Retirement Saving Incentives?

In this area it would be prudent policy to ensure that there are strong incentives for people to provide for their own retirement with an emphasis on the acquisition of an income stream as opposed to a lump sum that can be 'frittered' away over a relatively short period of time. As well, if elderly people can be encouraged to defer the take up of the aged pension by staying in the workforce the call on the public purse can be reduced. Examples of policy options, some of which will be unpopular and politically difficult to implement, include:

  • superannuation: current superannuation arrangements in Australia are very complex and have developed in a very ad hoc manner. The central aim of superannuation is to provide an income stream in retirement. In Australia, superannuation contributions are taxed concessionally and at all three levels of the contribution cycle, a situation that is unique in the world. According to the Chief Executive Officer of the Association of Superannuation Funds Australia, Phillipa Smith:

Australia has the unenviable record of 'leading' the world in taxing super, being the only country that taxes superannuation at each stage of its life cycle - contributions, earnings and benefits - and for many there is an additional super surcharge. A key objective in any tax reform exercise should be to reduce this complexity and to move towards a system where only benefits are taxed - not contributions or fund earnings.(33)

Given that superannuation is designed to provide resources for the future, it should only be seen as providing taxation revenue to the government in the future. It should not be taxed now to fund current commitments.

As well as only taxing superannuation at the point it is taken, the rate at which it is taxed should also be simplified. Currently, taxation rates on superannuation taken as a lump sum can vary from 0 per cent to 47 per cent, depending on the amount of the lump sum, when it was acquired and the scheme involved. However, most superannuation lump sums are taxed well below the maximum 47 per cent level. In order to encourage people to take their superannuation as a pension rather than as a lump sum, current taxation arrangements should be altered (providing a long phase in period) for superannuation taken as a lump sum. If all lump sums over a certain threshold amount (say $30 000) were taxed at 35 per cent (approximately the average marginal tax rate) there would be a strong incentive for people to take their money as an ongoing pension. This would help reduce the number of people who take a lump sum, spend it, and then go onto the age pension. Additionally, the Government could legislate to allow people over 70 years of age to contribute to superannuation as a further measure to encourage people to stay in the workforce for longer periods. At present, superannuation funds cannot accept contributions from people aged over 70, save for a few exceptional circumstances related to ill health and caring for children.

Retirement savings accounts (RSAs) were introduced in July 1997 as another vehicle for saving for retirement. The taxation provisions on these RSAs are the same as for other superannuation arrangements. Thus, any changes to taxes on superannuation would also apply to these accounts.

  • expanding on the Pension Bonus Scheme: the Pension Bonus Scheme (introduced in July 1998) allows people of pension age (currently 65 for men and 61 for women) to defer taking up their pension entitlement in return for receiving an increased benefit at a later date. The Bonus is paid as a lump sum and is paid for each full year that the pension is deferred due to the person staying in the workforce. Whilst in the workforce, they must work at least 25 hours per week. The Bonus is equivalent to 9.4 per cent of the Age or Service pension that the person is entitled to for each year of deferral, multiplied by the number of years deferred. The longest period that the pension can be deferred for is five years. Under existing arrangements the maximum lump sum that could be claimed is $21 250 which is equivalent to 47 per cent (9.4 per cent x 5 years) of the annual maximum pension ($9042), multiplied by five. If this Scheme was made more attractive (for example, by extending the number of years that the pension can be deferred from five to eight and/or increasing the bonus percentage from 9.4 per cent to 15 per cent) then more elderly people would be encouraged to stay in the workforce for longer periods, thus further reducing the call on public revenue. The present Bonus Scheme is estimated to save $18.4 million in 1998-1999 and $43.6 million in 1999-2000(34) and, if it is extended, even higher savings could be expected.

Better Employment Opportunities for Older People?

Building on the Pension Bonus Scheme could be specific policies designed to encourage older people to stay in the workforce or rejoin the workforce. Again, this would help reduce the call on savings and the social security system as older people stayed in jobs rather than retiring. The need for such policies is evident when data on work force participation by the elderly is examined. Over the period 1973 to 1993, fulltime labour force participation by males aged 55 to 64 years declined from 79 per cent to 52 per cent.(35)

An example, of a specific program set up to encourage and support older people in the workforce is the European-based EuroWork Age program:

The program is part of a wider commitment of the European Council to urge Member States to give special attention to the difficult situation faced by older workers...The purposes of EuroWork Age are to: identify and disseminate existing good practice regarding the management of an ageing workforce and equally importantly the way in which older workers are managing change themselves [and] work with others to promote a policy arena in which individuals, organisations and Member States can implement action.(36)

Old Age/Retirement Levy?

As is the case in many overseas countries, consideration should be given to the development of long-term private care insurance to supplement the existing arrangements for funding retirement incomes. Apart from the existing national health insurance scheme (Medicare), Australia does not have any broad based social insurance programs. Much of what is provided is funded from general revenue and contributions to superannuation schemes.

A recent study undertaken at the University of Western Sydney (Macarthur)(37) proposed a comprehensive scheme (the Ensuring Quality of Later Life or EQOLL model) for financing the needs of aged care well into the next century. The advantage of the EQOLL proposal is that it provides choice as to how individuals would like to help fund their care in old age as well as ensuring that the revenue raised is specifically set aside for the purpose that it is intended:

Under the proposed EQOLL model all Australians aged over 25 and earning more than $15,000 pa. would be required to set aside 1.1% of their taxable income per annum from 2000-2011 in one of four forms of aged care insurance in order to be eligible for an array of aged care services and to cover their future aged care costs at no additional cost than the pre-1997 regime of charges. (38)

The four options given under the EQOLL model would be:

  • a 1.1 per cent aged care supplementary payment that would operate in a similar fashion to the existing Medicare levy. Revenue raised from this supplementary payment would be used to pay for residential aged care services and would ensure that contributors would pay no more for their care than was the case prior to the Aged Care Act 1997 reforms. This Act included the provision for additional user fees, particularly in nursing homes and has been the source of considerable controversy in the residential aged care sector. Those who preferred not to pay the supplementary payment could avoid doing so by taking out comprehensive aged care insurance
  • an equivalent 1.1 per cent of taxable income to be invested in an approved life insurance fund similar to that offered by superannuation funds. This option would supplement existing superannuation arrangements and could form part of future enterprise productivity agreements
  • the taking out of appropriate aged care insurance from an approved private health insurance fund
  • investment of at least 1.1 per cent of taxable income in Continuing Care Retirement Communities. The investment would be permitted only in facilities that provided a range of full, self contained aged care and health services.

The EQOLL model, as well as suggesting ways of helping finance aged care, also provides for a number of initiatives (using the additional revenue raised) to more generally help the elderly contribute to Australian society. This includes:

  • the allocation of 0.3 per cent of the revenue raised (about $10 million per annum) to 'celebrate and promote the strengths and productivity that our country gains from our senior citizens'
  • the allocation of a further 0.3 per cent to fund a series of 'phased initiatives, beginning in the year 2000, which relate to the experience and the likely preferences of the different generations reaching the age of fifty five', and
  • allocating 0.1 per cent (about $3.3 million per annum) of the revenue raised to advance the cause of volunteers in Australia.(39)

Extending the Medicare Levy?

Failing the introduction of a comprehensive system such as that outlined above, the first 'leg' of that proposal (a Medicare supplementary payment) could be introduced on its own. A long-term care component could be 'piggybacked' on to the Medicare levy and progressively increased over a period of ten to twenty years with a view to it being at its maximum when the peak of the 'baby boomers' reach retirement age. Precedent for this exists in the form of the 'gun levy' that was added to the Medicare levy following the Port Arthur massacre. The advantage of this type of arrangement is that it would be simple to implement given that the Medicare levy is already operating. It has the additional advantage of being a tax that is relatively well accepted by the population as whole:

Australians have accepted occasional increase in the Medicare levy. If one accepts the inevitability of public recognition of long-term care as a normal risk of growing old and which the whole population requires protection against, a further increment in the levy may be seen as an acceptable initial step towards, on the one hand, easing some of the cost of long-term care in Australia and, on the other, ensuring that those disabled elderly who are living in the community have access to long-term care services as an entitlement.(40)

Tighter Targeting of Aged Income Support?

The structure of the existing income and assets test which apply to Age and Service Pensions offers considerable scope for reform to tighten eligibility without affecting those elderly people who are in most need of income support. Three possible areas for reform are:

  • investments in real estate are not income tested under the extended deeming regime introduced in July 1996. Only actual income is considered. Real estate assets which produce no income or less than market income, such as holiday homes, vacant land or hobby farms could be included under the deeming provisions to encourage re-investment in productive assets
  • the family home is completely exempt under the assets test. For example, any value over $750 000 or a million dollars could be included in the calculation of a pensioner's assets to encourage investment in productive assets
  • the Assets Test applies to only a small portion of the pensioner population. If the allowable asset levels were reduced and the withdrawal rate under the assets test was reduced, more people would have pensions reduced under the assets test. This change could arguably result in a better targeted pension system.

Constraining Growth in Health Outlays?

Health financing and expenditure are policy areas where little agreement exists on problems, directions and solutions. Health expenditure is increasing in Australia, as in most other OECD countries, having risen from $5.71 billion in 1975-76 to $43.07 billion in 1996-97. Expenditure on health services does tend to increase as people age. For example, in 1993-94, 35 per cent of total health system expenditure was spent on people aged 65 years and over, while this group comprises less than 12 per cent of the population. Some 20 per cent of total health system expenditure was spent on people aged 75 years and older, although this group comprises less than 5 per cent of the population.(41)

Expenditure on health is often portrayed as a 'burden' or a 'cost' and calls have been made, particularly by economic commentators, for individuals to take more responsibility for their own health care costs. Simplistic solutions are often proposed, such as compulsory co-payments for medical services and means testing of access to public hospitals. Neither these nor similar proposals are themselves solutions to increasing health costs but could be considered along with other proposals, such as increasing the rate of the Medicare levy (with an accompanying decrease in personal income tax rates) to better reflect the actual cost to government of the provision of health services. Other options include current initiatives which aim to promote the provision of quality health services and treatment, including appropriate prescribing of medication for the elderly and evidence-based medicine.

It should be noted that individuals already contribute directly a substantial amount of funding to support Australia's health system. In 1995-96, for example, individuals contributed $6.3 billion by way of out-of-pocket costs for health and medical services, $4.4 billion by way of premiums paid to health insurance funds and $3.4 billion through the Medicare levy. Another important point to note in any discussion of health financing is that the bulk of health expenditure is spent on a small proportion of the population, those people who are chronically ill. For example, it has been estimated that nearly 50 per cent of total health expenditure is spent on 10 per cent of the population.

There are three key drivers of health expenditure in Australia: expectations of consumers, advances in technology and the ageing of the population. Contrary to the claims of many commentators, it can be argued that the ageing of the population of itself will not necessarily pose a serious threat to health financing in Australia in the near and mid future.(42) However, when combined with the two other factors, there is little doubt that Australia will potentially face some difficulties if present policy settings remain unchanged.

Future Funding

It is necessary, therefore, to give consideration to how the Australian health system may best be financed in the future. Countries often look to the international experience to inform future policy directions, however in the health care arena, there are few definitive models to draw upon. For example, in the 1980s and early 1990s, both the United Kingdom and New Zealand turned to the market and competition as a means of controlling increasing expenditure by their governments on health care. The United States has utilised managed care as the centrepiece of its approach to controlling increasing health care expenditure in both the government and non-government sectors. Singapore has developed a somewhat unique system of health care financing which relies heavily on self-reliance.

Both the UK and New Zealand are now withdrawing from the less successful elements of their experiment with the market and are moving towards cooperation rather than competition. In the United States, patients, providers and some legislators are becoming increasingly concerned with the excesses of managed care. The Singapore model, while superficially attractive, would require major modification before it could be seriously considered as an option for Australia.

It can be argued that prior to (or at least as well as) an examination of financing options, a key issue which requires the attention of policy makers and the community in general is the commencement of a debate on what Australia's health system can realistically be expected to provide in the future. This is not solely a debate about whether financing is provided by the public sector or the private sector, although this is an important component of such a debate. Neither is it a debate about mechanisms such as co-payments, means-testing or user-pays, although again, these are components of the debate. Rather, the debate is about setting priorities for the allocation of resources for health care and, ultimately, about rationing.

Rationing Access To Care?

In relation to health care, rationing is a term which is seldom raised in Australia (with the notable exception of commentators such as Professor Stephen Leeder and Professor Peter Baume).(43) However, vigorous and occasionally fruitful debate and discussion has ensued in other countries, including New Zealand, the United Kingdom and parts of the United States. It is inevitable that priorities are set and health services are rationed in any health system because there are not sufficient funds (public or private) to provide every person with access to every possible health intervention.(44) Even the United States, with its massive expenditure on health care (14.2 per cent of GDP compared to Australia's 8.5 per cent)(45) and large non-government sector, rations access to health services quite ruthlessly, albeit largely in an implicit manner.

Health services in Australia are currently rationed implicitly through a variety of mechanisms. The most obvious mechanism is through waiting lists for elective surgery in public hospitals, but other forms of rationing include the exclusion of services provided by non-medical practitioners such as dentists, physiotherapists (some services are provided in public hospitals), podiatrists and chiropractors from the publicly funded Medicare and the exclusion of some pharmaceuticals, medicines and preparations from subsidy under the Pharmaceutical Benefits Scheme (PBS). This situation can lead to the provision of less appropriate care, and/or the exacerbation of conditions which remain untreated simply because a person lacks the ability to pay for a service which is not available under Medicare or not subsidised under the PBS. Some of the trials of co-ordinated care, which are currently underway, are investigating the possibilities of funding access to services not currently covered by Medicare where these services are provided under case management.

In order to ensure that sufficient funding is available in the future to provide equitable access to adequate health services and treatment, it is important to commence the building of a dialogue on priorities for the allocation of resources for health care which involves all the community. The setting of priorities and the rationing of health services in Australia currently occurs largely in an implicit manner, involving practitioners, policy makers and administrators. Commentators such as Professor Peter Baume argue that the priorities being set and the choices being made need to become much more transparent and explicit. Questions to be addressed include:

  • which decisions should be made
  • who should make these decisions, and when, and
  • who will and who will not obtain services.(46)

Given that the community funds the Australian health system, both directly and indirectly, it can be argued that the community has both the right and the responsibility to be involved in the debate on these and other difficult questions. Due to their higher average use of health services, it can be argued that the population aged over 65 years has a greater stake in the health system than the community in general. The imperative is even stronger, then, for this group to become involved in any discussion of the sort of health system that is required in Australia and how much the community is prepared to pay for such a system. Priority setting and rationing of resources for health are not optional issues. All that is optional is whether the community is prepared to accept the challenge of open and transparent discussion and decision-making on these issues.

More User Pays?

There have been moves towards more user payments in parts of the aged care system in recent years, particularly with respect to nursing home fees and charges for Home and Community (HACC) services. As part of the Aged Care Reform Strategy (see page 13), the current Government introduced accommodation charges for new residents in nursing homes as well as income-based daily fees.(47) These charging arrangements are similar to those that have been imposed in hostels for many years. At the same time the government has proposed that more consistent and uniform fees be charged for HACC services in all the States and Territories. As yet, this has not occurred, with most jurisdictions charging less than the Commonwealth would like. Over time, a policy option could be to extend these user pays type arrangements with the emphasis on ability to pay. However, given the controversy over the nursing home charges, there is no doubt that this would be politically unpopular. Nevertheless, given the apparent lack of capital funding for nursing homes it would appear that the Government has two options to overcome this lack of funding-more user pays and/or additional funding from its own sources.

A Higher Rate of Immigration?

The general consensus regarding the role of immigration with respect to slowing down the rate of ageing of the population is that it will and could only play a very minor role. Apart from the fact that a large rise in the rate of immigration would, in all likelihood be politically unpopular and in some eyes be seen to cause significant economic and social dislocation, there would be only be a marginal affect of such a policy on the rate of ageing. According to EPAC in its recent report on ageing:(48)

Even the most ambitious migration program, by historical standards, would not eliminate a substantial increase in age dependency ratios. The ageing of the population structure must therefore be addressed directly through effective retirement income policies, health care reform, support of the disabled etc.

For further discussion on this issue see a forthcoming Research Note, Immigration and Ageing, Department of the Parliamentary Library.

Other?

'One stop shops' for the elderly, partly funded by government and supported by the community sector, could be established throughout Australia to give 'seamless' advice on ageing and retirement issues. The aim would be to have a one stop location to obtain information and advice in this very complex area. The information and advice should cover all relevant areas including the roles and services/support provided by the three tiers of government as well as information on services provided by the private and community sectors. This is particularly important given the amount of insecurity and uncertainty that many older people have been experiencing in recent times due to significant policy changes in the area of old age support. Better and more accessible sources of information may well help to reduce this level of insecurity and uncertainty.

Additional resources devoted to the general well being of the elderly (sport and recreation, volunteerism) would also be of benefit and help delay the call on more costly health and care provisions. The encouragement of the elderly to participate more actively in community activities (such as visiting schools) already exists to a limited degree and could be expanded.

The Overseas Experience: Some Examples

Two Differing Models

The majority of developed countries provide a range of benefits for the elderly including age pensions, health and other long-term care support. Some countries such as the USA tend more towards the private provision of such benefits while others, notably the Scandinavian countries, rely more on government provision and funding of benefits. In the USA, although the publicly funded Medicare provides cover for many health costs it is expected that those with means should provide for their own long-term aged care expenses. By contrast, the Scandinavian countries essentially provide a publicly financed broad based safety net. The advantages and disadvantages of these two differing approaches to funding aged care are described by Agnes Walker as follows:

The benefit of the Scandinavian model is that it provides all people with a relatively generous minimum living standard. As a result, in these countries poverty in old age is now a marginal phenomenon...The disadvantage is that it places a heavy burden on the public purse. It thus relies on Scandinavians accepting very high levels of taxation. With tighter budgets and higher unemployment in recent years Scandinavians, as well as people in other countries, have questioned the future affordability of existing levels of support...The benefit of the US model is that the demand for health and aged care services is generally market driven, since most individuals are responsible for the costs of the services they consume. Demand is thus rationed by what people can afford. The disadvantages are that the gap between the rich and the poor is widened, that minimum living standards are lower than in other developed countries and that a relatively high proportion of people live in poverty, with resulting high levels of crime etc. In the United States the private provision of services has led to high health expenditure, which currently accounts for around 14 per cents of GDP [compared to 8 per cent in Australia]...

Overall, many developed countries are questioning the affordability of existing systems, seeking alternatives that are able to contain costs without affecting the quality of care...While asking individuals to bear a greater share of their age related costs seems an attractive solution, the experience in the United States suggests that there could be significant disadvantages in moving too far in the 'private provision' direction. The general view is that there is no 'correct' balance in public versus private financing. For each country the final compromise will depend on what its people accept as being both socially desirable and financially responsible. (49)

Of the two models described above, Australia more closely accords to the Scandinavian experience with a much more comprehensive and generous welfare system than that existing in the USA.

Examples of Retirement Income Policies

Most countries have policies designed to provide income support for workers when they retire. Due to rising unemployment and industry 'restructuring' in the late 1970s and 1980s many countries moved toward incentives for early retirement. However, in recent years the tendency has been more towards policies designed to slow the rate of early retirement-for example, in Australia progressively increasing the eligible pension age for women and the Pension Bonus Scheme (see page 19 above). Another example of this is Sweden, where recently the age at which the pension could be claimed was raised from 65 to 67 and, over time, lower pensions are to be paid to those who retire before age 61 and higher pensions are to be paid to those who work until 67 years or later. (50)

The following overview of retirement income policies in selected countries is heavily drawn from Retirement Incomes Around The World: Global Trends and Implications for Employers.(51) The overview shows that all the countries examined are reforming their systems with the common approach being to bring in policies designed to reduce the level of benefits available over time as well as progressively extending upwards the age eligibility at which many of the benefits can be accessed.

The United Kingdom

Two key features of the United Kingdom system in recent years have been the tightening up of earning related benefits paid via the social security system and the increased regulation of private pension plans, essentially as a result of the Maxwell pension scandal of the early 1990s (whereby a poorly regulated private pension scheme collapsed).

The social security system provides a basic pension as well as an earnings related benefits (the State Earnings Related Pension Scheme) pension that varies according to average salary levels earnt throughout a working life. Employers also provide retirement plan benefits which are usually paid in the form of a pension annuity, with part of the amount being able to be taken as a lump sum.

At present social security benefits are payable at age 65 for men and 60 for women, but recent legislation provides for a progressive phasing in (from 2010) of a later eligibility age for women. By 2020 the eligibility age for women will also be 65 years.

Early in 1998 a Royal Commission on Long-term Care for the Elderly was established. The Report of the Royal Commission is due to be released in late 1998 or early 1999.

Japan

A key issue facing Japan's retirement income system is the country's rapidly increasing dependency ratio (the ratio of the population aged over 65 divided by the size of the workforce), which is predicted to increase from 23 per cent at present to 57 per cent by 2040.(52)

The social security system has two main strands-the National Pension Plan (a flat rate benefit paid on retirement) and the Employee's Pension Insurance Scheme (an earnings related benefit payable at age 60). Most employers also provide a range of retirement benefits similar to the type of superannuation arrangements that apply in Australia. These include lump sum retirement allowances, qualifying pension plans and employee pension funds.

In recent years the Japanese social security system has been 'tightened up' with benefits in general being reduced, the indexation formula being changed, contribution rates being increased from 14.5 per cent of pay to 17.35 per cent of pay and a gradual increase in the eligibility age for the National Pension from 60 to 65.

France

The French system includes both social security benefits and compulsory, complementary retirement programs. For workers on lower salaries social security provides a pension that varies according to the number of years the worker has been in the workforce. Eligibility for this pension begins at 60. The number of years that a worker has to work to qualify for the top rate of pension is progressively being increased to 40 years, while eligibility for payment of the average rate of pension is being progressively increased to 25 years in the workforce.

There are two compulsory, complementary retirement programs which are essentially designed to cover those workers who are not eligible for the social security pension. On average workers in these programs pay 14 per cent of their salary into the fund/s and, on retirement, they receive a benefit related to their contribution levels. In recent years there has been a reduction in the level of benefit available under the compulsory programs as the French Government tries to cope with funding one of the world's fastest growing aged populations.

 

Canada

The Canadian system has three main strands:

  • an Old Age Security pension that provides a basic indexed pension to those aged 65 and over
  • the Canada and Quebec Pension Plans which are worker specific compulsory retirement plans that workers (and employers) contribute to at a rate of 3.2 per cent of salary. The aim is to provide workers with a pension on retirement that is worth approximately 25 per cent of their career average salary. Benefits are fully indexed and payable at age 60, however, benefits are reduced by 6 per cent for every year that retirement precedes 65 years of age
  • various profit sharing, pension and retirement savings plans that receive favourable tax treatment. These plans can be company sponsored or individually sponsored and various limits are set on the amount of contributions and the amount of benefits that can be accumulated.

The Canadian Government has recently introduced reforms to help ensure the long-term viability of the system including increases in employer and employee contribution rates (to 9.9 per cent in 2003) under the Canadian Pension Plan and the proposed replacement of the Old Age Security pension with a new 'Seniors Benefit' in 2001. Included in the latter reform will be tightened eligibility requirements.

Conclusion

Whilst opinion may vary as to just what the effects of ageing may be on Australian society over the next fifty years and beyond, there is no doubt that policy adjustments will need to be made. The overseas experience shows a trend towards tightening eligibility for age care benefits combined with a greater role for private provision of retirement incomes. However, appropriate policy settings in Australia may be difficult to achieve given the likely political strength of the baby boomer generation. Already the phenomenon of 'grey power' is well recognised and acknowledged and with a large 'boomer' population that is not only well educated and articulate, but also dominant in many of the positions of power and influence in society, policy makers will need to be bold and courageous if the appropriate policy decisions are to be made.

Prudent policy making should include a strategic approach involving a holistic view of ageing and long lead times so as to minimise the potential for social and economic dislocation. Given that 1999 is the International Year of Older Persons, it would seem opportune that now is the time for government and the community to fully examine the myriad of issues associated with an ageing population with a view to achieving some sort of consensus as to just what might be the appropriate policy settings for the future. The current Commonwealth Government has already moved in this direction with the establishment, in November 1997, of the National Strategy for An Ageing Australia. The Strategy includes provision for a wide range of consultations with all levels of government and the community and private sectors. A number of discussion papers looking at the host of issues involved with an ageing population are due to be released over time as part of the Strategy. Given adequate resourcing and support the Strategy would appear to be the best vehicle to approach and deal with Australia's ageing population into the next century.

Endnotes

  1. Australian Bureau of Statistics, Population Projections 1997 to 2051, Catalogue No. 3222.0.

  2. Australian Bureau of Statistics, Census of Population and Housing, Catalogue No. 2015.0, July 1997.

  3. Ibid.

  4. Department of Immigration and Multicultural Affairs, Australia's Population Trends and Prospects 1996, p. xv.

  5. Australian Bureau of Statistics, Catalogue 2015.0, op. cit.

  6. Australian Bureau of Statistics, Population by Age and Sex, Catalogue No. 3201.0.

  7. Ross Clare and Ashok Tupule, Australia's Ageing Society, EPAC Background Paper No. 37, January 1994, p. 19.

  8. Australian Bureau of Statistics, Catalogue No. 2015.0, op. cit.

  9. S. Mathur, Aged Care Services in Australia's States and Territories, Australian Institutue of Health and Welfare, Canberra, 1996, p. 6.

  10. Ibid., p. 7.

  11. Australian Bureau of Statistics, Catalogue No. 3102.0, p. 34-35.

  12. Ross Clare and Ashok Tupule, op. cit.

  13. It is important to note that this is the total expenditure on health services in Australia, not merely the contributions by government, nor is it only expenditure on Medicare. Total health expenditure includes: expenditure by the Commonwealth, State, Territory and local governments; private health insurance funds; out-of-pocket costs of patients; workers compensation and third party insurers. Health services include: medical and hospital services; pharmaceuticals; ambulance services; dental services; other professional services; community and public health services; aids and appliances; research; nursing homes and administration.

  14. Australian Institute of Health and Welfare, Older Australia at a glance, http://gallifrey.aihw.gov.au/publications/w_online/oag/oag.htm . [19 November 1998]

  15. Ibid.

  16. OECD, Maintaining Prosperity in an Ageing Society, 1998, pp. 3, 4.

  17. National Commission of Audit, Report to the Government, AGPS, Canberra, June 1996.

  18. Ibid., p. 122.

  19. It should be noted that Australia's total health expenditure in 1996-97 accounted for 8.5 per cent of GDP. Expenditure by government accounts for approximately 65 per cent of total health expenditure.

  20. Argy, Fred, 'Such a CAD is truly not worth worrying about', The Canberra Times, 28 August 1998.

  21. Commonwealth Budget Paper No. 1, 1998-99, pp. 4-55

  22. Australian Institute of Health and Welfare, Australia's Welfare 1993: Services and Assistance, AIHW, Canberra, 1993, pp. 201-202.

  23. Australian Bureau of Statistics, Australian Social Trends 1996, p. 151.

  24. Ibid.

  25. The Minister for Family Services, The Hon. Warwick Smith MP, Media Release, 12 May 1998.

  26. Compiled from Commonwealth Budget Papers by Michael Fine in SPRC Newsletter, June 1998, p. 7.

  27. Australian Institute of Health and Welfare, Nursing homes in Australia 1996-97: a statistical overview, AIHW, Canberra, 1998, p. 1.

  28. For more details see G. McIntosh, Residential Aged Care: New Fees and Charges, Research Note No. 34 1997-98, Dept. of the Parliamentary Library, March 1998.

  29. Budget Paper No. 1, 1997-97, pp. 3-38.

  30. Strategic Ageing: Australian Issues in Ageing - 1998-99 Commonwealth Budget Submission, Council on the Ageing (Australia) Vol. 5, 1998, p. 10.

  31. Australian Institute of Health and Welfare, Older Australia at a glance, op. cit.

  32. Denys Correll, Council on the Ageing, private correspondence, 2 November 1998.

  33. Smith, Phillippa, 'Savings fall well short', The Australian Financial Review, 1 October 1998, p. 19.

  34. Social Security and Veterans' Affairs Legislation Amendment (Pension Bonus Scheme) Bill 1998, Explanatory Memorandum.

  35. Council On Ageing (Australia), op. cit., p. 41.

  36. Ibid., p. 40.

  37. John McCallum, Peter Botsman, et al., Ensuring quality of later life: financing aged care services within the context of an aging society, Centre for Health Outcomes and Innovations Research, University of Western Sydney, September 1998.

  38. Ibid., p. x.

  39. Ibid., p. xi.

  40. Alan Borrowski, 'Financing long-term care for the aged: Israel's long-term care insurance law', Social Security Journal, September 1997, p. 67.

  41. C. Mathers et al. Health system costs of diseases and injury in Australia 1993-94, AIHW, Canberra, 1998.

  42. J. Hall, 'Health costs boom for baby boomers?', inTouch, May 1998, p. 9.

  43. See, for example P. Baume, 'Rationing in Australian health care services', Medical Journal of Australia, 19 January 1998, pp. 52-3.

  44. J. Richardson, 'Economics as a prerequisite to an ethical allocation of health resources', Healthcover, October-November 1996, pp. 45-49.

  45. Australian Institute of Health and Welfare, Australia's Health 1998, AIHW, Canberra, 1998.

  46. P. Baume, op. cit., p. 52.

  47. For details of the new fees and charges in nursing homes and hostels see G. McIntosh, Residential Aged Care: New Fees and Charges, op. cit.

  48. Ross Clare and Ashok Tupule, Australia's Ageing Society, op. cit., p. 17.

  49. Agnes Walker, Australia's ageing population: what are the key issues and available methods of analysis?, Discussion Paper No. 27, National Centre for Social and Economic Modelling, February 1998, pp. 4-5.

  50. Ibid., p. 6.

  51. Towers and Perrin, SuperNews, 1998.

  52. Ibid., p. 22.

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