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Dr Luke Buckmaster
Mandy Biggs
Social Policy Section
Introduction
The 2007–08 health budget includes new expenditure in a range of areas
across the health portfolio. A number of these new measures have been
welcomed by the Opposition and interest groups. For example, the Shadow
Minister for Health, Nicola Roxon, welcomed additional funding for health
and medical research ($485 million in grants to leading research facilities),
the Royal Flying Doctor Service and the establishment of a new dental
school at Charles Sturt University.[1]
The Australian Medical Association (AMA) welcomed new funding for Indigenous
health, aged care, combating obesity, rural health dental care, chronic
disease and after-hours GP services (although with the reservation that
actual funding amounts were ‘well short of what is needed to make a real
difference’).[2]
Perhaps the two most strongly contested areas of political debate in
the health portfolio over the past year have been dental health and preventive
health (particularly in the area of chronic disease). The Government made
two announcements in the Budget directly related to these areas. These
announcements, as well as measures regarded by some commentators and interest
groups as significant omissions from the Budget, will be examined below.
Prevention of chronic disease
Background
For much of this year, the question of whether the Australian Government
places sufficient emphasis on policies aimed at preventing chronic disease
in the community has been the subject of much political debate. Chronic
diseases are generally defined as those characterised by such features
as complex and multiple causes, (usually) gradual onset, and long duration
involving gradual deterioration of health. Cardiovascular disease, cancers,
diabetes, asthma, arthritis and other musculoskeletal conditions are examples
of chronic diseases.
Chronic diseases are widely regarded as a significant health concern
both in Australia and internationally. In addition to the threat posed
to individual quality of life through physical limitations and disability,
chronic diseases pose particular problems for health systems. People with
chronic diseases are frequent and extended users of the health services.
This means that they are associated with high health expenditure. The
major chronic diseases account for around 70 per cent of total health
expenditure in Australia.[3]
The National Chronic Disease Strategy has argued that preventive strategies
should be a major part of efforts to address the problem of chronic disease
because ‘a number of the major chronic diseases can be prevented or their
onset delayed.’[4] However,
it also notes that, on the whole, the health system remains oriented towards
acute and short term responses.[5]
Further, national expenditure on public health activities such as health
promotion and prevention remains at a relatively low level (only 1.7 per
cent of total recurrent health expenditure in 2004–05 was directed to
public health).[6]
This situation has led many commentators to call for the Australian health
system to be reoriented towards preventive strategies for healthcare delivery
and funding. That is, on the promotion of health, rather than treatment
of disease. The then Health Minister, Senator Kay Patterson, made this
point in 2002 when she argued that prevention should become the ‘fourth
pillar’ of Medicare, alongside the Pharmaceutical Benefits Scheme, the
Medicare Benefit Scheme and public hospital services.’[7]
In recent years, Commonwealth health budgets have included a variety
of measures which the Government has described as being part of an increasing
focus on preventive health. These have included measures directed at specific
diseases, as well as initiatives aimed at greater involvement of general
practitioners (GPs) in prevention (e.g., through the introduction of new
Medicare items). The Commonwealth has also increasingly collaborated with
the states and territories on strategies aimed at preventing chronic disease
through, for example, the National
Chronic Disease Strategy and the Australian
Better Health Initiative.
The political debate around prevention in recent months has focused on
the question of whether Australian Government efforts in this area are
sufficient. For example, Shadow Health Minister, Nicola Roxon, has sought
to highlight the threat posed by chronic disease to national productivity
(also raised in recent reports such as the 2006 Access Economics report,
The
Economic Costs of Obesity, and the 2007 Productivity Commission
report, Potential
Benefits of the National Reform Agenda), and argued for a greater
focus on prevention from the Government.[8] The Minister for Health and Ageing, Tony Abbott, has rejected
the proposition that the Government is not sufficiently oriented towards
the prevention of chronic disease, arguing that, for example, in 2006,
‘through Medicare the government spent some $200 million on preventive
health and treating chronic disease with 650,000 GP team care plans; 250,000 team care
plans; 500,000 allied health consultations; and some 250,000 senior health
checks.’[9]
Prevention and chronic disease budget measures
In the 2007–08 Budget, the Government has announced additional funding
of $236 million for ‘measures to help Australians to avoid preventable
chronic illness.’[10]
The measures include:
- $103.4 million over four years for a new program to identify those
at risk of type 2 diabetes and help for them to modify risky behaviours.
This implements a COAG announcement from 13 April 2007. The program
is to be delivered through GPs and risk will be evaluated on the basis
of a standardised survey (or ‘tick test’). People at risk of developing
type 2 diabetes may be referred to accredited ‘lifestyle modification
programs’
- $10.6 million over four years for a series of national nutrition
and physical activity surveys aimed at enhancing understanding of lifestyle
related health problems and developing education campaigns to help people
avoid such problems
- new public information and education campaigns on the health benefits
of breastfeeding ($8.7 million) and the prevention of Hepatitis C ($17
million) and sexually transmitted infections ($9.8 million)—all over
four years. The current national education campaign on skin cancer will
also be extended at a cost of $11.5 million over two years
- one-off grants totalling $11.7 million over four years for physical
activity projects in the community and
- extended eligibility for two cholesterol lowering drugs through the
Pharmaceutical Benefits Scheme to help people at risk of developing
heart disease ($77.6 million over four years).
The Budget also includes other measures which, while not
included in the prevention announcement, address the problem of chronic
disease. These include:
- $291.3 million over four years for new Medicare items to enable patients
with chronic and complex illnesses to receive longer, more comprehensive
care sessions from consultant physicians
- $337.6 million over four years through Medicare to help people whose
chronic conditions are made (or are likely to be made ) worse by poor
oral health (see below for an analysis of the dental health budget measure)
and
- $57 million over four years on other measures, including the continuation
of the Sharing Health Care Initiative to help people better manage chronic
conditions through informed self-management.
These measures, like those in previous budgets aimed at preventing and
managing chronic disease, represent a range of approaches and target a
range of health problems. The largest financial commitments are to be
provided through Medicare via the primary care system. The use of the
primary care system to help prevent chronic disease is widely regarded
as an important part of the prevention agenda. It is consistent with the
Government’s approach in previous years and will most likely assist many
people. One concern, though, is that (as discussed in the section on dental
health) evidence suggesting that only a very small percentage of those
with chronic diseases in Australia have actually been placed on a care
management plan does not inspire great confidence in this as the primary
mechanism for preventing or managing such diseases.
As such, while the package of chronic disease measures will most likely
lead to improvements for many people, it is probably best characterised
as moving the health system only incrementally in the direction of a greater
orientation towards prevention. For example, it appears unlikely to provide
much of a boost to the current level of national expenditure on prevention-related
activities (which, as noted above, is around only 1.7 per cent of total
recurrent health expenditure). The package is also, on the whole, relatively
limited in scope in that it targets a number of important chronic health
problems (or aspects of chronic health problems) such as diabetes or obesity.
However, it fails to bring them together as part of a more integrated
or comprehensive strategy.[11]
Dental health
Although the provision of public dental services is largely funded by
the states and territories, the Commonwealth has funded dental benefits
in the past (the School Dental Scheme in the 1970s and the Commonwealth
Dental Health Program in the mid 1990s are examples), and continues to
fund certain dental services today (such as the Cleft Lip and Cleft Palate
Scheme and dental services for service personnel and veterans). Since
July 2004 limited dental treatments through Medicare have been available
for eligible patients with chronic conditions on referral from their GP.
As access to dental health care has become an important public issue,
fuelled by media reports of up to 650 000 Australians on public dental
waiting lists, calls for a greater Commonwealth role in funding dental
services have increased. A number of recent parliamentary inquiries have
recommended increased Commonwealth funding (although none advocated funding
dental care through Medicare).[12]
Additional pressure has come from within government with some government
backbenchers calling for increased dental funding in this year’s budget.
The 2007–08 Budget provides funding of $377.6 million to expand Medicare
benefits for dental services for patients with chronic conditions and
complex care needs (and some residents of aged care facilities). Eligible
patients will be able to claim Medicare benefits (up to a maximum of $2000
per year including extended Medicare Safety Net benefits) for a range
of dental services, on referral from their GP, provided they have a GP
Management Plan and Team Care Arrangement in place.[13] Full details of the services are yet to be finalised, but will
include a diagnostic consultation and a range of dental services.
This measure expands Medicare benefits for dental treatment that were
first introduced in 2004 as part of a broader allied health care initiative
for people with chronic conditions.[14] At the time the Government emphasised this initiative was as
a health measure ‘not a dental care scheme.’[15]
The allied health component has proven popular with over half a million
allied health services provided in 2005–06, but uptake of the dental component
has been considerably lower with only 5532 services provided.[16]
The Government estimates that around 200 000 patients will benefit
under the enhanced dental care items to be made available by this expanded
measure, but it is unclear how this target will be achieved. Although
there are currently around 392 000 GP Management Plans in place to
manage patients with chronic conditions, few patients on these plans have
taken up the option of dental treatment using the currently available
Medicare items.[17] High out-of-pocket costs have
been recorded, with departmental figures showing some patients paying
up to $692 extra for certain services.[18] Strict eligibility requirements may also be
inhibiting uptake.[19]
This expanded measure in this year’s budget addresses some of the financial
barriers faced by patients by increasing the maximum amount that can be
claimed from Medicare in a calendar year from $220 to $2000, and expanding
the range of dental services available. However, where in the past high
out-of-pocket costs incurred by the patient counted towards the extended
Medicare Safety Net (thus easing the financial burden of further medical
costs), this may no longer apply to patients accessing dental treatment.
Although full details are yet to emerge, concern has been raised that
that the total cost of dental services incurred by Medicare will be capped
at $2000—including the cost to Medicare of the extended Medicare Safety
Net[20]. If this is the case, dental
patients may have to meet the ‘gap’ between the Medicare rebate and the
fee charged by the dentist once the cap is reached, potentially eroding
the benefit of the increased amount that can be claimed.
In addition many Australians with chronic conditions and dental problems
will not be eligible for the dental benefits, even under the expanded
dental services that will be introduced. There is some evidence to suggest
that only a small percentage of those eligible are actually placed on
a GP Management Plan (a prerequisite for accessing dental benefits).[21]
While this budget introduces some measures to improve the management
of chronic disease, for example, additional funding for extended consultations
with specialist doctors (see discussion above), improvements to the uptake
of GP Management Plans and further reducing financial barriers are required
before the benefits of this dental initiative will be seen.
Omissions
According to some health groups a number of health areas have been neglected
in this budget. The criticisms include that this budget does not provide
enough spending for Indigenous health, obesity, rural health, chronic
disease and dental care, even though the Budget provided some funding
for each of these areas.[22]
Budget initiatives for Indigenous health have come in for particular
criticism from the AMA. The Budget provides for just over $121 million
in new spending for Indigenous health, well short of the extra $460 million
the AMA has called for.[23]
Specific initiatives in the Budget include funding to family centred primary
care, a nurse-led home visiting program for mothers and babies, improved
accreditation for Indigenous health services, Indigenous workforce improvements
and expansion of the Indigenous scholarship scheme. Although the Government
has provided funding for some of the initiatives recommended by the AMA
in its 2007–08 budget submission, such as the mothers and babies’ initiative,
other recommendations were not funded.[24]
These include funding a national rheumatic heart disease program and implementation
of the Australian Indigenous Doctor’s Healthy Futures Best Practice
Framework. The surplus from this year’s budget may well have been
regarded as an opportunity for the Government to address more comprehensively
the poor state of Indigenous health. However, government priorities appear
to have favoured other areas of the Budget in general, and other areas
of health spending.
The Rural Doctors Association of Australia (RDAA) has also been strongly
critical of the Budget as having failed to provide sufficient measures
to increase the numbers of rural practitioners or improve access to healthcare
services in rural and remote Australia.[25] One measure that the RDAA had been hoping for was a rural-specific
Medicare item ‘to compensate rural doctors for the professional and family
isolation, and the increased skills and responsibility, of rural and remote
practice.’[26]
Endnotes
[1]. N. Roxon (Shadow Minister
for Health and Ageing), Health budget gets some things right–but there
are big gaps, media release, 9 May 2007, http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=pressrel&Criteria=CITATION_ID:4L0N6%3B,
accessed on 17 May 2007.
[2]. Australian Medical Association,
Health budget 2007—a budget of downpayments: little steps not giant
leaps, media release, 9 May 2007, http://www.ama.com.au/web.nsf/doc/WEEN-72ZCL5,
accessed on 17 May 2007.
[3]. National Health Priority
Action Council (NHPAC), National Chronic Disease Strategy, Department
of Health and Ageing, 2005, pp. 2–3, http://www.health.gov.au/internet/wcms/publishing.nsf/Content/7E7E9140A3D3A3BCCA257140007AB32B/$File/stratal3.pdf,
accessed on 17 May 2007.
[4]. ibid., p. 3.
[5]. ibid.
[6]. Australian Institute of Health
and Welfare (AIHW), Health Expenditure Australia 2004–05, AIHW,
Canberra, 2006, p. 55 (figure 18), http://www.aihw.gov.au/publications/hwe/hea04-05/hea04-05.pdf,
accessed on 17 May 2007.
[7]. K. Patterson (Minister
for Health and Ageing), New study backs Government's preventative approach
to health, media release, 25 November 2002, http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-mediarel-yr2002-kp-kp02129.htm,
accessed on 17 May 2007.
[8]. N. Roxon (Shadow Minister
for Health and Ageing), Preventable illness: the health budget’s “climate
change” threat: speech to AFR 9th Annual Health
Congress, media release, 21 February 2007, http://parlinfoweb.parl.net/parlinfo/Repository1/Media/pressrel/E2AM60.pdf,
accessed on 17 May 2007.
[9]. Tony Abbott, Minister
for Health and Ageing, ‘Questions Without Notice: Health’, House of Representatives,
Debates, 28 February 2007, p. 74, http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=hansardr&Criteria=DOC_DATE:2007-02-28%3BSEQ_NUM:57%3B,
accessed on 17 May 2007.
[10]. T. Abbott (Minister for Health
and Ageing), Preventing chronic disease, media release, 8 May 2007,
http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2007-hmedia06.htm,
accessed on 17 May 2007.
[11]. For examples of possible
alternative approaches see S. Willcox, Purchasing prevention: making
every cent count: background paper, National Health Policy Roundtable,
8 August 2006, http://parlinfoweb.parl.net/parlinfo/Repository1/Library/miscitem/KTJK60.pdf;
and P. Gross, S. Leeder and M. Lewis, ‘Australia confronts the challenge
of chronic disease’, Medical Journal of Australia, vol. 179, no.
5, 1 September 2003, pp. 233-34, http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=jrnart&Criteria=CITATION_ID:22BA6%3B,
accessed on 17 May 2007.
[12]. Notably the 2003 Senate Select
Committee’s first inquiry into Medicare; last year’s NSW parliamentary
inquiry into dental services; and more recently the House of Representatives
inquiry into health funding.
[13]. T. Abbott (Minister
for Health and Ageing), Improving Medicare and hearing services,
media release, 8 May 2007, http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2007-hmedia01.htm,
accessed on 17 May 2007.
[14]. T. Abbott (Minister
for Health and Ageing), Allied health workers to help the chronically
ill through Medicare, media release, 7 June 2004 http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=pressrel&Criteria=CITATION_ID:VYQC6%3B.
This was for certain allied health and dental care services for patients
with chronic conditions. Full details are available at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Allied+Health+and+Dental+Care+initiative,
accessed 10 May 2007.
[15]. T. Abbott (Minister for Health
and Ageing), MedicarePlus, media release, 10 March 2004, http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=pressrel&Criteria=CITATION_ID:7VWB6%3B,
accessed on 17 May 2007.
[16]. Senate Standing Committee
on Community Affairs, Answers to Estimates Questions on Notice, Question
no. E06-142, Health and Ageing Portfolio, Supplementary Budget Estimates,
2006–07, 1 November 2006.
[17]. The numbers of people with
GP Management Plan or Team Care Arrangement in place are drawn from the
Senate Community Affairs Committee, Answers to Estimates Questions on
Notice, Question no. E06-140, Health and Ageing Portfolio, Supplementary
Budget Estimates 2006–2007, 1 November 2006.
[18]. ibid. For item number 10977,
Assessment or treatment by Dental Specialist. On average, out-of-pocket
costs for dental items were $61 compared to an average $11 for other allied
health items.
[19]. See the Department of Health
and Ageing website for full details of eligibility requirements., http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-dental-cnt.htm,
accessed on 10 May 2007.
[20]. L. Russell, ‘Dental scheme
well-funded but not well planned’, Canberra Times, 11 May 2007,
http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=pressclp&Criteria=CITATION_ID:O41N6%3B,
accessed on 17 May 2007.
[21]. M. Georgeff, E-health
and the Transformation of Healthcare, Australian Centre for Health
Research, South Melbourne, April 2007, p. 3, http://www.achr.com.au/pdfs/ehealth%20and%20the%20transofrmation%20of%20healthcare.pdf,
accessed on 17 May 2007.
[22]. G. McArthur, ‘Health
spending criticised’, Herald Sun, 10 May 2007, http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=pressclp&Criteria=CITATION_ID:MW0N6%3B,
accessed on 17 May 2007.
[23]. C. Siew-Yong, quoted in ‘The
reaction: doctors’, Canberra Times, 9 May 2007, http://parlinfoweb.aph.gov.au/piweb/TranslateWIPILink.aspx?Folder=pressclp&Criteria=CITATION_ID:0C0N6%3B,
accessed on 17 May 2007.
[24]. AMA, Fixing Indigenous
health and stepping up the fight against obesity top AMA budget wish list,
media release, 23 November 2006, http://www.ama.com.au/web.nsf/doc/WEEN-6VT2MZ,
accessed on 17 May 2007.
[25]. Rural Doctors Association
of Australia, Rural health forgotten in Budget ‘07, media release,
8 May 2007, http://parlinfoweb.parl.net/parlinfo/Repository1/Media/pressrel/GQ2N60.pdf,
accessed on 17 May 2007.
[26]. ibid.
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