Minister for Health and Aged Care – National Press Club – Q&A transcript – 2 May 2023

Read the transcript for Minister Butler's Q&A at the National Press Club on 2 May 2023.

The Hon Mark Butler MP
Minister for Health and Aged Care

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I thought I would kick off with a question that connects with the savings measure that you have just announced. $3.3 billion over four years from a higher excise on tobacco. I will break a rule here and ask two questions.


Firstly, is that all going back into Medicare? A related one, before our broadcast today, we had a series of health awards, the health award for this year, the top award went to Adele Ferguson and Chris Gilette for series on fraud in Medicare and you commissioned a task force that looked at fraud in Medicare. It reported back with an estimate that $1.5-3 billion a year is lost in fraud, given we are a week out from the Budget, should we expect any action in the Budget that addresses fraud in order to recover money and then to reinvest that in Medicare?



Thank you, David. Undisciplined start to proceedings with two questions. To your second question first, Mr Philip conducted a thorough and quick review for us. We are working through that. Some of the recommendations from Mr Philip will be relatively easy and quick to implement. Some of them are incredibly complex and will take time to work through. We are looking through the recommendations and we will give a response in due course. There is more to come in the Budget next week around Medicare and I am pretty much at my limit as to what I have preannounced.

On your first question, though. I am really proud of the fact that so much of this excise that will be raised will be reinvested into health, not absolutely every dollar will be but there are very substantial health programs that are going to be able to be reinvested, including the lung cancer screening program, because we are taking this measure. I might recap for people: under the last government, tobacco excise increased by well over 100% during their term in government.

We are proposing three 5% increases. Excise had stopped increasing in about 2020 and since that time, excise increases have actually started to lag inflation, particularly last year.

We are determined not to see the price of cigarettes start to become more attractive as against CPI. We have got to continue to send that price signal that Nicola Roxon argued so persuasively and comprehensively for 10 years ago. Plus there is the benefit that we are able to use some of that revenue to invest in these important health programs.


DAVID CROWE, MODERATOR: Before we go on, I should note...


BUTLER: A third question?


DAVID CROWE, MODERATOR: No, no, I would not dare. I just want to note that you can hear the Minister's voice - he is losing his voice. He has been doing major addresses and a bunch of interviews. Bear with us on that, if you need to take a break, let us know. Our next question is from Tom Connell.


TOM CONNELL, JOURNALIST: I will note Port played on Friday in a close game as well. That could be another reason for the voice.


BUTLER: I am pretty sure we won, Tom.


CONNELL: You got them over the line. It is great to be here in a full room. Not so long under COVID restrictions, these lunches were 12 masked journalists, not a bread roll in sight and Morrison was doing his best but it was a sad state of affairs. COVID smashed hospitality, it changed our lives and locked us down, people couldn't get back into the country, some people couldn't visit dying relatives and hundreds of billions of dollars in debt. We know what it did. We still don't have a definitive report on what was worth it, why decisions were taken and when asked about a Royal Commission, Anthony Albanese has said several times, and he has been in power a while now, that we are dealing with COVID and that is our priority. Experts say we could be dealing with it forever. What sort of time frame are we waiting for, what is the trigger, when will your government be able to announce a Royal Commission on COVID?


BUTLER: We said before the election and have said since, just given the enormous dislocation, stress, death and expenditure involved in this pandemic, it would be extraordinary not to have a thorough inquiry into it and that remains our position. Particularly through the course of last year and summer, where there were significant waves that posed a lot of stress on health systems and communities, we didn't think that was the right time to announce that. We are giving consideration to this question. We will have more to say about that in the future.


JOURNALIST: You took us on a history tour in your speech, Minister. You have decided to introduce a new MyMedicare program as part of your reforms in the Budget. This will allow wrap around care of people. When Kevin Rudd was Prime Minister, he introduced a program for diabetes patients that paid doctors $1,200 a year to provide wraparound care. Doctors wouldn't have a bar of it, it failed. The previous Health Minister Greg Hunt introduced Health Care Homes, same idea, doctors were given a budget to provide wrap around care for patients and it failed. A review found it didn't improve patient outcomes. What is more magical about your solution and how much is a doctor going to get paid to provide that wrap around care? What is the budget per patient under your program?


BUTLER: As I said, the costings of that will become clear after next Tuesday night. The diabetes care pilot that we conducted when we were last in government had some very good results. I agree it was contested at the time. Some of the different pilots that have taken place since, including the health care homes pilot conducted under the former government also had mixed results. In the Strengthening Medicare Taskforce we looked carefully at all of that. We looked at the work that had been conducted to develop the 10-Year Primary Care Plan that was released in the former government's last Budget and there was a striking degree of consensus that has built up around the need for some of the bundled or more flexible funding models to sit on top of fee for service, a much greater degree of consensus than there certainly was when we were last in government.


I am confident we will get the costings right and given the soundings we have had with AMA and the College of GPs and many others, that there is an appetite out there to step into this new future for Medicare. It is a very different one which is why it will take time to build. We are not in a rush to do it. We want to get it right because the Grattan Institute said we have had more pilots than Qantas over the past 10-20 years. They were right on that. Everyone is done with more pilots. We want to see some systemic change that is built at a steady sure rate and learning as we go. I am confident we are doing that.


CROWE: The journalism awards were earlier and Monique from SBS was an award winner. Congratulations, Monique.


MONIQUE PUEBLOS, JOURNALIST: Monique, SBS Insight. You mentioned squashing the black market on vapes but although nicotine vapes are prescription-only in Australia, the black market is thriving. Given the history of prohibition, does the Government have any concerns that the ban will only make this issue worse?


BUTLER: I don't think - Rachel Stephen Smith is here the ACT Health Minister and we had a discussion yesterday and the Health Ministers are determined to do this and urgently but under no illusion about the challenge. This thing has flourished in front of our eyes. We all know this as we interact as parents or uncles and aunties with young school students. It is just flourishing, particularly over the course of COVID. We are going to have to shut down an industry, a market that has been allowed to grow up, in spite of the fact that it wasn't really supposed to.


The prescription model meant that this wasn't supposed to happen. State and territory governments, very rightly say, what are they supposed to do if the borders are open, if there is no import control? Greg Hunt, to his credit, tried to do this. He was well intentioned. I think he saw the risk that was ahead of us, but his party room didn't let him do it.


We will have strong controls on the borders. We will resource that properly. We will sit down with state and territory government to make sure we get the resourcing right both at the border and on the ground with state and territory authorities, going and checking that the convenience stores aren't breaking the law. That is what they will be doing. We are under no illusion about how hard this will be. We have a real sense from the community, certainly from the health sector, that we have to deal with this now. This is a moment to shut down a major health risk to the youngest generation of Australians, after doing so much work over so many decades and many people in this room have been part of it, to drive down smoking as the biggest killer of Australians, the idea that we would just put a new generation at risk, creating a new generation of nicotine addicts, go untouched is just beyond us. It will be tough, but we are determined to do it.


CROWE: Next question from Tom McIlroy.


TOM MCILROY, JOURNALIST: The Treasurer regularly cites health and aged care as two of the biggest pressures on the Federal Budget along with repaying debt, the growth in the NDIS and defence, things like that. Is that inevitable going forward in an ageing society like Australia, or will there be changes to spending in the health portfolio to manage that in a better way?


BUTLER: Both. It is not an either or. Aged care, we know, is simply a product of demographics. We have known for years, if not decades, that the ageing of the baby boomer generation and every generation after them – because they are all big, I mean my generation is bigger than the baby boomer generation – will mean additional costs. You invest in that, in the same way that during a baby boom itself you invest in schools. This is the right and proper thing to do. To an extent, there is going to be a rise in the costs associated with supporting a generation that worked hard, paid their taxes, raised their families and built this community. We should recognise the reality of that, the Inter-Generational Report that comes out later this year will set out some of the numbers to refresh our understanding of it but, yes, this is inevitable in the ageing space. We have to make sure we spend the money right, that we get a sustainable mix about who is funding this. That is something we are giving consideration to now. In the broader health space, if you look at PBS, after the pricing reforms that were put in place 15 years ago, the expectation 20 years ago that PBS would overwhelm the budget hasn't come to pass.


Growth in the Medicare Benefits Schedule has been relatively modest also. Growth is substantial in hospitals. We are talking with states about that. We have a mid-term review of the hospital funding agreement that has just kicked off.


All of us want to make sure every dollar we spend in health is spent wisely. We have got to look out for inefficient, non-productive uses of scarce health funding and make sure it is used in the best way. In a lot of areas of health, we have managed to control spending pretty well. In some areas, particularly associated with ageing, there is going to be a rise in per capita spending for an older population but we have got to make sure that is done smartly.


HOST: Natasha Robinson from The Australian, also commended earlier in the health journalism awards, congratulations, Natasha.


NATASHA ROBINSON, JOURNALIST: You have talked a lot since you have been Minister about the crisis in general practice, how it has never been harder to see a doctor, that people are paying more gap fees than ever. How will this package that you are announcing in the Budget and the reforms that you are instituting over the next few years solve the fundamental problem that the rebate is now so low that it just doesn't cover the cost anywhere near the actual cost of seeing a doctor? It also causes the problem that you have talked about, about a lack of attractiveness in going into the profession. While your reforms are welcome, aren't you going to still be left with this problem going forward, at least in the next few years?


BUTLER: Thanks, Natasha. I tried to stress that there is more in the Budget in health. There is more in the Budget that reflects our Strengthening Medicare agenda. The items that the Prime Minister took to National Cabinet were items that we thought would be a productive discussion between state and territories. For example, we want their cooperation in the identification of the frequent flyers in hospitals. There is more to come. We are very conscious of the financial pressure that particularly general practice is under. I have talked a lot about that. We have been thinking very carefully through ways in which we can alleviate that financial pressure. We can't undo several years of Medicare rebate freeze in one fell swoop. That is difficult.


This is our most important priority. I have said that from the time I was appointed as Health Minister: there is no higher priority than rebuilding general practice. It is part of relieving some of that pressure today, that you have written about, Natasha, it is also about rebuilding the attractiveness of general practice as a career for our young medical graduates. You know the statistics: 14% of medical graduates now are choosing to go into general practice. It used to be 50%. If you think it is hard to get a GP now, 10 years down the track, if we don't turn that around, we will be in all sorts of difficulty. General practice being the backbone of the health care system means that would reverberate through the broader health system, particularly into our hospitals. We will have a comprehensive look at this.


In improving the attractiveness of general practice for young medical graduates, I have talked to young doctors through the AMA and through the college and it is not just about money - yes, it is about money a bit, it is also about culture, and it is also about the respect that general practice attracts from their governments but also others in the health sector, including some of their supervising physicians in hospitals. We will have to look at this comprehensively. Rest assured that there is no higher priority for me than rebuilding general practice, because it is in the worst state, certainly I think, that it has been in the 40 year history of Medicare.


CROWE: The next question is from Andrew Brown.


ANDREW BROWN, JOURNALIST: Andrew Brown from AAP. Thanks for your speech. How would you consider the changes to vaping to be successful? Would they be contingent on smoking rates to go down to levels they were before vaping was more pronounced, would it be a decline in vaping the same levels as cigarettes among the broader population, would it only be young people or would it be vaping stopping altogether?


BUTLER: I want vaping to return to the purpose that we were told it was invented for, that is a therapeutic product to help long term smokers quit. We were promised this was a pathway out of smoking, not a pathway into smoking. That is what it has become. That is what it has been sold as so shamelessly and presented as: vapes deliberately disguised as highlighter pens so kids can hide them in their pencil case and smoke them at school or vape them at school. This is the most shameless piece of marketing that I have seen in my time, particularly in the health sector. If I have a key indicator, it is to stamp out the idea that this is a recreational product at all but particularly a recreational product for our kids. Knocking that market out is what I am aiming for. We also want to see smoking rates continue to come down, we want to see smoking rates plateau and then come down in that crucial under 25 cohort as well which is why there are very substantial investments in that, including for the first time in many years a funded tobacco information campaign that will be particularly focused on young people.


CROWE: Our next question is Natassia from the Sydney Morning Herald and The Age.


NATASSISA CHRYSANTHOS, JOURNALIST: Going back to general practice, you have discussed a bunch of measures today that will inject more into GPs, such as the after-hours funding, the Workforce Incentive Program, the MyMedicare system and reading between the lines of your speech earlier, there will be some form of Medicare rebate increase for general practitioners in the Budget. Should Australians, therefore, expect to see a rise in bulk billing rates and a decline in the average gap fee they pay? At what point should they be able to see that outcome? Going back to your opening remarks, where you mentioned the increase in corporate ownership of general practice, which is another structural force at play, if there is an increase in Medicare rebates for GPs, how will you ensure this is passed onto the consumer and gap fees don't stay where they are or continue to grow?


BUTLER: We are focused on that: if there is going to be investment in this Budget to make sure it ends up benefitting patients directly. I have said publicly since before we were elected, how concerned I was at what was happening with the bulk billing rates. I don't think that was coming through the data that was published by the former government. We have worked with Brendan and my Department to get a different type of data being presented to the public, it has become clear what patients and doctors have been telling us is real. Bulk billing is in very substantial decline. Some communities, it is really hard to find a bulk billing doctor, including here in the ACT. In Western and South Western Sydney, it is relatively common. It is hard to explain why there are such differences in different parts of the country.


At the top of my list of concerns is the decline in bulk billing. What we have seen over the last 12 months or so, increasingly, are stories about pensioners and concession card holders also now being charged a gap fee. That is a profound change to the way in which we understand the access and affordability of primary care services. Those are the things that have been shaping our thinking. You will have to wait until next Tuesday night.


JOURNALIST: Thanks for your speech Minister. Under this framework where it would be illegal for an adult to buy a vape without a prescription but not a cigarette, I want to ask the long term policy direction, is that an inconsistency that you plan on addressing by banning smoking or phasing out smoking by birth year as they are doing in New Zealand?


BUTLER: We have no plans to do that. This might be a minor nuance, but it is important. Our focus is not on the people buying, our focus is on the people selling. This has been a vendor-driven, corporate-driven phenomenon that we have seen. When we talk about enforcement, the state and territory governments and us are focused very much on importers and vendors, not on the customer themselves. We want to knock out the market. We are not blaming the customers. They have been sold a pup. We have all been sold a pup. We have been duped. The difference between vaping and cigarettes is that cigarettes have been with us for so long. If we knew now back then when cigarettes were being introduced, I would hope that governments would have stopped it, would have snuffed it out immediately which is what I want to do to vapes. We have a closing window here before vapes become so widespread, so accepted, so normalised as frankly some want them to be, the National Party for example, that it would be very difficult to take any action. I am still confident that the thing is still relatively new and we are going to be able to take the action that I have outlined today. No plans to do what New Zealand has done at this stage.


CROWE: The next question from Claudia Long from the ABC.


CLAUDIA LONG, JOURNALIST: In 2019 Labor committed to linking hospital funding to the provision of abortion to make sure terminations were accessible and free. That has been dropped from your platform since. I am interested to know what specifically has it been replaced with and to make sure that this service is accessible and also, should patients expect to see something around this in next week's Budget or will they need to wait longer than that?


BUTLER: We are still very committed as a matter of principle to equitable access across the country to reproductive health and terminations services. It is a particular issue in rural and regional Australia. In some states more than others. This is something we are focused on, something we have had a discussion from time to time as Health Ministers about. In the Federal Parliament, there is a Senate Inquiry, I think as you would know, into these issues and this has been an inquiry that has been well received out in the community. A lot of interest and submissions, some public hearings. We are looking forward to the results of that inquiry and we will consider those recommendations.


LONG: Is that when you plan to make a concrete plan to improve access? As you know, it is a big problem, it is legal but inaccessible for many people. You had a concrete solution before and it seems like there is a gap there - not a gap but people are interested to know, are you waiting on an inquiry to make that decision?


BUTLER: States or territory governments are primarily responsible for these services and I know that there is activity underway at state and territory level but, yes, we think the proper thing to do is to wait the outcome of that Inquiry, consider the recommendations and we will provide a response in time.


JOURNALIST: I am really not quite convinced of that answer you gave before about compliance. When any of us here can walk into any smoke shop and buy unregulated, under the counter chop chop, when I raise this question with a friend of mine who is a vaper, he just said they will just sell it under the counter unregulated or "I will just buy my vape juice online". How can we guarantee that a similar situation is not going to happen as we are seeing with the illegal durries trade? Why not sell it for over 18s regulated and taxed over the counter with the other smokes?


BUTLER: Because I am not going to normalise a product that is deliberately designed, in my view, to create a new generation of nicotine addicts. Evidence shows it is becoming a pathway back into smoking, to smoking cigarettes. I am not going to do it. There is no public health argument for that. The under the counter sale of these things is not something that might happen in the future, it is happening right now. It is happening in a way that effectively has no compliance or enforcement activity behind it because state and territory governments quite rightly say “you at a Commonwealth level have let the border open. You have let them come in.” We will do what we need to do, close the border, put in place compliance resources through Border Force, the TGA will be making our position clear on that in due course, but work cooperatively with state and territory governments to get that important compliance and enforcement activity happening at a grass roots level in retail settings. As to chop, chop which you talked about as well. We do recognise that this is also a loophole in all of the regulation we have put in place, particularly the pricing signals around tobacco and as part of our excise measure, we are committed to working more with some of the enforcement mechanisms we have at a federal level, including the ATO, but with state and territory governments in trying to reduce that. I recognise that is hard and they don't come in in shipping containers with a label "vapes" or "chop, chop" and this is hard work we are expecting of our authorities, but we are determined, it is something we simply have to do.


JOURNALIST: When you look at this regime and talk to the states and territories about how to set it up, do you want criminal sanctions against retailers who sell and flout the rules that you want to bring in, is that something that you want the states and territories to do because enforcement would primarily be up to them?


BUTLER: There will be activity we will have to put in place, particularly around borders and imports but there will be activity that we expect state and territories will have to undertake as well. We had a good discussion about that yesterday, all the Health Ministers tasked our officials at all jurisdictional levels to commence work immediately. What that comprehensive regulatory framework will look like also, what penalties look like, and all those things will be a matter for that sort of work and we want that to be put in place urgently.


CROWE: Next question is from Nick Stuart.


NICK STUART, JOURNALIST: You made the important point when you began that Medicare was a terrific system when introduced. It is now 40 years later. At this stage, do we actually need to stop considering - you made the point that there is a shrinking number of GPs, do we actually, rather than reinforcing the Medicare system which relies on the GP as the first step in the health system, do we need to actually reenvisage it, so that in your local shops you actually go to a medical centre where there is not merely a doctor but also a physiotherapist, also a psychological assistant or a pharmaceutical person so that way it is all an integrated approach?


BUTLER: I think the market has set up these one stop shops, much more than you will remember when 40 years ago when general practices were very small, cottage industries, only a couple of GPs maybe working there and you would have to go to different premises to access some of the services -


STUART: I do remember that but that is a bit rude to say that – *laughs*


BUTLER: I remember it too. It was a question of solidarity between us, Nick. The market is setting that up because that is what patients want and it is what they need, the joined-up care. Here in the ACT, there is the terrific example of nurse-led clinics that have been very successful. They were contested, they were hard for the ACT Government under then Katy Gallagher to set up. They have proven their worth, in terms of avoided hospital admissions, avoided general practice presentations. What I also said in my speech is although general practice is utterly central to the functioning of a proper health care system, we can get much more out of our health care professionals, out of nurses and nurse practitioners, out of pharmacists and health professionals and that is something that I think we are all committed to doing and including the doctor representatives who are on the Strengthening Medicare Taskforce.


JOURNALIST: What are you going to do to help rural Australia that has the highest levels of medical work force shortages and some of the biggest numbers of long-term chronic health issues?


BUTLER: This has been a challenge for as long as we have had a health care system in Australia, in ways that it is getting easier because there are telehealth connections that people are able to use that, to a degree, close down that tyranny of distance. When we came into government, we promised to restore the rural loading for telehealth sessions for psychiatrists that I put in place when I was Minister for Mental Health more than a decade ago. That is a really important way for people to be able to get psychiatry support if they are living in communities that simply don't have a psychiatrist. I am particularly very clear and cognisant that access to standard general practice services is even harder in rural and regional Australia than some of the challenges we have talked about existing in our cities.


We have a strong incentives program for people to go and work as GPs in rural and regional communities, in October we increased some of the incentives. We are trying to put in place different models to broaden the pipeline of young GPs who want to train and then work in rural and regional Australia, some terrific innovations that we announced down in Tasmania, a single employer model, so someone is employed by a hospital, able to work in general practice while they train. We are confident that will improve the pipeline. There is much more that I think we need to do. The representatives of rural and regional medicine who are on the Strengthening Medicare Taskforce were clear that some of these models that might work in cities are still going to be a challenge in rural and regional Australia and we are going to have to continue to do work on that.


CROWE: The last question is from Tom Connell.


CONNELL: I get two. Noting your 60-day prescription medicines policy, you noted it brought Australia up to speed with the UK and New Zealand. After those policies are in the UK an estimated 1100 pharmacies shut and in New Zealand it was 70. Has your department done work to see how many pharmacies could close in Australia and will you monitor the situation if they are starting to shut or threatening to, to be able to step in and avoid that happening?


BUTLER: We will monitor that closely. I also said when I announced this that we would reinvest every single dollar that the Commonwealth taxpayer saves through this measure, it is substantial and it is $1.2 billion over the forwards. We would be investing every single dollar back into pharmacy programs. We will monitor that. I have said every occasion I have had the chance to as Health Minister, I want to see a thriving community pharmacy sector delivering more services, not just processing repeat scripts but delivering more health services to their customers. Their customers had a wonderful experience in a difficult few years through COVID because their pharmacy doors were always open. Talking to customers, if anything, their trust, their relationship with their pharmacist has grown over the course of COVID and that is a great opportunity for us to broaden the work that pharmacists do. I am determined, if I am given advice by the Pharmaceutical Benefits Advisory Committee, advice that has been in place for five years, of a way to halve the cost of medicines for six million Australians living with chronic disease, I will take it up. But you are not quite right in your question, because we didn't come into line with a number of other countries because a number of other countries, some of which you mentioned, allow 90-day dispensing, not 60 days. If anything, there are more savings that are put in place in those other countries. That was a recommendation put to me by the Committee. I didn't think it was appropriate to go with now. I thought the proper balance was 60 days and I still think it is the right one.


CROWE: Thank you, very much, Minister. We will wrap up there. I want to thank you for being here today, taking 15 questions or more when your voice is showing the strains of the pre-Budget period. I would like to present you with complementary membership to the National Press Club. You are welcome back here at any time. Thank you for the address.

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