Minister for Health and Aged Care - press conference - 29 January 2024

Read the transcript from Minister Butler's press conference which covered the 40th anniversary of Medicare, bulk billing, mental health and healthcare affordability.

The Hon Mark Butler MP
Minister for Health and Aged Care

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MINISTER FOR HEALTH AND AGED CARE, MARK BUTLER: There's nothing more important than a good functioning health care system to support the health of Australians. We know that it's been under very real pressure. First of all: demographic changes, many of which we've known about for years, the aging of the population, the almost inexorable increase in chronic disease and mental illness place real pressure on a system that was not designed to deal with that type of illness. We also know, all too well, the impact of 10 years of cuts and neglect Medicare have had on the system broadly, but particularly on general practice, and there’s rightly been much discussion in this room and beyond about that. And thirdly, as with every healthcare system across the world, health is facing the legacy issues and pressures imposed by four years of a once-in-a-century pandemic: an exhausted workforce, a whole lot of deferred care and increased acuity because people didn't get their cancer screenings at times of lockdown, density restrictions and such like, people didn't go and visit the doctor for their chronic disease for the same reasons, when they probably should have and would have, had there not been a whole range of COVID restrictions in place.
So, our system along with healthcare systems right across the world, is facing real pressure, facing real challenges that our Government is committed to addressing. But without minimising those challenges, it is also important that we recognise that the quality of Australia's healthcare and the quality of the work that is delivered by literally hundreds of thousands of hardworking, well-trained – some of the best trained in the world – healthcare professionals that we have the privilege of living with here in Australia.
There are a range of different reports that measure the quality of Australia's healthcare system comparatively at a global level. Perhaps the most often cited is The Commonwealth Fund’s work. It's most recent report, in 2021, found that of the key developed nations in the OECD, Australia's healthcare system was ranked at number three, overall. Ranked at number three, behind Norway and the Netherlands. In important measures, it was ranked even higher. For health outcomes, Australia's healthcare system ranked number one in the developed world. For equity, Australia's healthcare system ranked number one in the world. And the key reason for that, I think, beyond any question, is: Medicare.
Along with the age pension, perhaps there is no more important element in Australia's social fabric than Medicare. And this week, on Thursday, the first of February Medicare celebrates its 40th birthday, or 40th anniversary.
And 40 years on, it's important to recognise a couple of things. The first is that it was hard fought. I've said over the weekend that for at least 25 years universal health insurance delivered by Medibank, by Gough, and then by Medicare by Bob Hawke, universal health insurance was perhaps the most defining fault line in national politics in this country. Since the late 1960s, when Gough Whitlam first presented this as a key element of his platform for election to the Prime Ministership, right until the early- to mid-1990s, when the Liberal Party finally dropped its formal commitment to abolish Medibank and Medicare in their entirety. It was the defining fault line. Both times that the Labor Government sought to introduce universal health insurance, first Whitlam in Medibank and then Hawke in Medicare, our Party faced very strong opposition. Those programs were fought tooth and nail, not just by the Liberal and National parties, but also by doctors’ groups, particularly the AMA.
The second thing to note about Medicare, though, is that it has been transformative. As you see, in those reports, including The Commonwealth Fund’s report, it delivers high quality healthcare. Now, I don't minimise in any way the challenges that our healthcare system is facing right now, because of all of those challenges that I mentioned. But there is no question that on life expectancy and so many other important measures of health care outcomes, Australia ranks right at the top of the global list. And the second thing that Medicare delivered, really importantly, is social equity, so that the quality of your health care and the quality of your health did not depend on the size of your bank balance or your credit card. Before Medicare, it's important to remember that individual healthcare bills were the number one cause of personal bankruptcies. After the introduction of Medicare, that measure was removed from the list altogether, because Medicare removed personal bankruptcies because of health care costs, entirely.
Now 40 years on, we take the view that the most important element of our social fabric, as I say, perhaps with the exception of the age pension, having survived and thrived all of its challenges for 40 years, should be celebrated and should be commemorated. And today, I announce at the beginning of the week which will celebrate the 40th birthday of Medicare, a number of modest and important commemorative activities. So alongside me, we have the commemorative Medicare card. If you go back and see the ads that Bob Hawke was heavily featured in, in only the first 10 months of his government, before the formal introduction of Medicare, this card has just become such an important feature of the wallets and purses of Australians. And we want to see that as people are getting new cards through the course of this year, from Thursday the 1st of February right up until the end of calendar 2024, that there will be that commemoration of the 40 year anniversary. As Neal Blewett said over the weekend, frankly, the Labor Government even under the great Bob Hawke did not expect Medicare to last for 40 years. It was fought so hard, by Liberal and National parties and by doctors, because there was such a strong commitment from John Howard, in particular, to abolish it in its entirety. And frankly, even those great reformers of the 1980s did not hope, even, that it would survive for 40 years.
The first element of our commemorative activities will be the hard cards that are sent to Australians if they're enrolling with Medicare for the first time or if they're getting a replacement card, will rightly have an acknowledgement of that important 40 year anniversary. All of the digital cards and the app will also be automatically updated online to reflect that important birthday as well. The second element of our modest commemorative activities will be an exhibition that will be launched here in Parliament House next week, when Parliament returns, and versions of which will be distributed and circulated right through the community at libraries and town halls and we hope school communities as well, to ensure there is a modest and important civics education process, that recognises the importance of 40 years of Medicare and all that it has delivered in healthcare outcomes, and social equity for our country. And also, to ensure that people can just refresh their understanding of the journey and what Medicare does deliver to Australians and their health. There'll be a commemorative website, very interactive, that ensures that people are able to access that information, educational activities are able to be undertaken at schools, right across the country that will be launched on Thursday, the 1st of February, as well.
We're really pleased to be able to talk about Medicare over the course of this week. Strengthening Medicare was a central feature of our budget last May, with more than $6 billion of new initiatives funded through that Budget, including obviously, as a centrepiece, the tripling of the bulk billing incentive that only took effect on the 1st of November. But 40 years is a long time in politics. And we in the Labor Party are very proud to have been the party that introduced universal health insurance to Australia: our first attempt in the 1970s, and then our second more successful attempt on the 1st of February 1984 under the great Prime Ministership of Bob Hawke and health ministry of Dr Neal Blewett. Happy to take questions.
JOURNALIST: Minister, you raised bulk billing, you say that you've tripled the bulk billing incentive. Back in August we saw there was a big drop in the bulk billing numbers, something like eight percentage points or something. What are the latest figures showing you and is there any excuse for a doctor in Australia not bulk billing a concession card holder?
BUTLER: They really are our principal focus around bulk billing. We like to see as much bulk billing as possible, but governments for some time have been particularly focused on pensioners, on concession cardholders, and on children under the age of 16. They account for about 60% of all activity in general practices. And given that we've increased general practitioner income for a bulk billed consultation for those Australians by about 34%, if you're undertaking a consult in our major cities and by as much as 50% in regional Australia, we think there's a very strong incentive now, for GPs to increase their level of bulk billing. Now, it's only less than three months since we implemented our Budget commitment from the 1st of November. We're hoping to have some real data to support the anecdotal feedback we've got that there has been a significant return to bulk billing, a significant renewed commitment to stay with bulk billing for those general practices who might have been considering the shift to imposing gap fees even on pensioners and kids. And I hope to have more to say about those data over coming days.
JOURNALIST: I thought the data actually came in fortnightly into the health department, if not more frequently. Surely, you would have some indication as to whether that measure has had any success.
BUTLER: We wanted to pull it together and to analyse it by regions. As I think I've said before, there's very, very different bulk billing behaviour in different markets. So, for example, western and south-western Sydney, where it's pretty expensive to run a business have traditionally - and still have - the highest rates of bulk billing in the country. Not far away in the Central Coast in the Hunter Valley in New South Wales and Tasmania, for example, much, much lower rates of bulk billing. There are quite different markets in general practice when it comes to bulk billing. We hope over coming days to have some good analysis of those data, which as you say, Andrew, we've been receiving.
JOURNALIST: Minister, that evidence has been collected, you just don’t want to release it today?
BUTLER: We haven't fully pulled it together. We'll have more to say about it in coming days.
JOURNALIST: Fewer than one in four GP clinics nationwide bulk bill all their patients. Backbenchers are saying publicly that medical bills are one of the key concerns for their constituents. Will you have to do something more in this area, ahead of the Budget?
BUTLER: We're getting about the job of implementing the Budget measures right now. And these are very significant investments. It's important to be clear how you are measuring bulk billing. The data you're referring to measures how many general practices bulk bill every patient, for every service, that comes through their doors. That is one measure. It's not the measure that we choose to use in the government. The measure we've been using after, frankly, overhauling the way in which the former government reported on bulk billing data, which we thought lacked transparency, is to ask how many GP consults are bulk billed. At the moment, it's about 75% of GP consults across the country are bulk billed. As I said, in response to Andrew’s question, those numbers are very different depending on what market you're looking at: Tasmania, relatively low, Western Sydney, relatively high, most of the country somewhere in between. But there's no question that that healthcare costs, whether it's medicines or the cost of going to a doctor, is a key cost of living pressure. And that's why it was such a feature of our 2023 Budget.
Cheaper medicines was a feature of our first Budget in October 2022. Over the course of 2023, we're able to deliver around quarter of a billion dollars in savings for Australian patients from cheaper medicines. And there's more to do there: more savings will accrue from those measures this year. And more measures in March and September will take effect for cheaper medicines, as well. So, you know, we're monitoring this really closely. We know healthcare is important. And, you know, we simply can't have a situation where Australians feel unable to take medicines that their doctors have prescribed for them or feel unable to go to a doctor because of affordability questions. That was one of the great signature objectives of Medicare and the Pharmaceutical Benefits Scheme before it - another great reform of a Labor government. So, you know, we will be looking at it very closely. We're going to talk to the College and the AMA and other consumer groups and others as we move into the Budget process. But right now, we're squarely focused on implementing the measures we funded in last year's Budget.
JOURNALIST: Minister, how do you smooth out some of those geographical discrepancies? Like you're saying some areas have higher rates, some areas have lower rates. To use, I guess, a local example here: I think most people who live in Canberra know that is quite hard to find a bulk billing doctor if not impossible. But how do you smooth that out? Because I think people would think that in the nation's capital city, which is quite, you know, well off, that will be relatively easy to find a local doctor.
BUTLER: As you know, we don't have a system like the National Health Service in the UK, we don't have a system that allows any civil conscription of doctors. Health services in primary care are delivered by private businesses that make their own decisions about the imposition of gap fees. As a Government, our job is to try and make it as attractive as possible for general practices to bulk bill all of their patients but particularly to bulk bill, those vulnerable patients: around 11 and a half million who account for 60% of their activity.
JOURNALIST: What do you think is a reasonable gap fee?
BUTLER: Our focus is on is on improving bulk billing. That is, that is where the vast bulk of the investment we put into general practice in last year's budget went. And that is what we're seeking to measure. And the more that we can incentivise and reward general practitioners for bulk billing those concession cardholders, pensioners and kids, the less pressure there is to impose gap fees on the rest of their patients as well.
JOURNALIST: You're talking about, like, the principles of Medicare? At what point I guess, do you look at the fees that a lot of non-concession patients are facing now, which is $60 for a 20 minute visit, and say, that's too much, and we're no longer abiding by the principle of what we want? Where's that threshold for you?
BUTLER: Our bulk billing incentive investment, as you know, focused on those concession cardholders, pensioners and children. But we're obviously very concerned about gap fees, whether it's for medicines or for GP and other primary care consults for non-concession cardholders, as well. As you know, our major initiative: the biggest cut to the price of medicines in the 75-year history of the PBS was squarely focused on non-concession cardholders. Because we know that those patients who might be on relatively low and middle incomes but don't qualify for a healthcare card, really feel the pressure of the medicine fees that were being imposed on them before we introduced that cut to the price of medicines for general patients. So, across a relatively short time in government, I think you will have seen investments that seek to reduce that cost of living pressure for healthcare from non-concession cardholders, particularly in the area of cheaper medicines as well as bulk billing for general practice consults. But we're concerned to look at this right across the population. We're focused, as I said, on implementing the initiatives we put in the May 2023 Budget, we're keeping a very close eye on gap fees on general practice charging behaviour right across the population.
JOURNALIST: Minister you were saying that you'd like to see more bulk billing, particularly for concession holders, what sort of messages are doctors’ groups and medical practices giving to us specifically about why they aren't bulk billing? And what would be needed to do aside from just increase concessions and like funding that the government can do can bring them on board to specifically boost billing rates that way?
BUTLER: The first thing to say is that the tripling of the bulk billing incentive, was perhaps the most significant request or Budget ask, if you like, from the College of General Practice in the lead in to the 2023 Budget. This was not something we designed on a blank sheet of paper, it was something that followed deep engagement with doctors’ groups, particularly the College of General Practitioners, and they said it was an important measure to re-incentivise, if you like, bulk billing behaviour in general practice. When we delivered it in the May 2023 Budget, the College described it as a ‘game changer.’ So, we want to see a response from general practice to the very significant investment, on behalf of taxpayers, that we made last May. Now, you know, there's obviously a lot of advocacy happening within the medical community, by the College and by other organisations that are analysing the impact of the bulk billing incentive. That's very broadly been supportive. As I said, to the question about different parts of the general practice system, for regional communities where it is harder to attract doctors and always has been, the average income for a general practice consult has increased by 50% because of the measure we introduced in May 2023 Budget. Now, given that that accounts for at least 60% of the business of the average general practice in regional Australia, that is a huge increase in general practice income for bulk billing behaviour. And it's exactly the sort of incentive that the medical community, particularly the general practice community through their College asked for.
JOURNALIST: Minister, but the question is, has it made any difference to doctors who weren't bulk billing now bulk billing. You’ve had three months now, surely you can give us some indication as to whether new doctors are bulk billing and how many have come on board?
BUTLER: And we will be. As you know, Andrew, when we came to government, and before we came to government, I expressed some real lack of confidence in the bulk billing data that was being published by the former government, particularly, to the extent it was skewed by the COVID measures, which had to be bulk billed because of the nature and the nature of the pandemic. And since then, I think everyone would accept that our bulk billing data that we are reporting, the degree to which it's reported by different region, by electorate, and so on and so forth, gives the media, consumer groups and doctors’ groups much more information to get their teeth into and to ask us the legitimate questions about the impact of our policies. Now, as I said, it's not quite three months -
JOURNALIST: It’s three months in two days, Minister.
BUTLER: You're right, it's three months in two days. We're keen to get that material out as quickly as possible. We want to know the extent to which we need to follow this up, if we do, in some regions, with more education, more information to general practice, communities. We want patients to know that if one practice in their area has changed their behaviour around bulk billing, and another hasn't, that it's entirely your right to vote with your feet.
JOURNALIST: You’re going to name and shame?
BUTLER: We're not going to name and shame. But people can ring around and ask “are you bulk billing a consult for my kid who's 14? Are you bulk billing me, I'm a pensioner, I'm a concession card holder.” We want an active community discussion about this. This is a big investment on behalf of taxpayers that we made in the Budget last year. And from Labor's point of view, as I've said, almost ad nauseam in the parliament, some suggest, bulk billing is the beating heart of Medicare for us. It was not for the former government. John Howard described it as an “absolute rort” and Peter Dutton famously said when he was Health Minister, there were “too many free Medicare services.” We don't take that view. We want to see that decline in bulk billing that really followed the long freeze of the Medicare rebate, we want to see that turned around, and we're going to be very open and transparent about it.
JOURNALIST: Is there any update on health insurance premiums? And what are you hoping that insurers come back to in terms of a reasonable level of price hikes?
BUTLER: As you know, I went back to private health insurers and urged them to sharpen their pencils. And that process is still underway.
JOURNALIST: There's still a lot of parts of healthcare that aren't accessible to a lot of people: dentistry, specialists, what are you doing to make sure healthcare in Australia is truly equitable?
BUTLER: Our priority focus has been general practice. I've said before we were elected, and since we were elected, I make no apology for that, for a couple of reasons. First, it is the backbone of our healthcare system. And secondly, I was desperately worried about the state of general practice as we came to government. You know, on any measure, whether it's anecdotally talking to people in the street, talking to doctors, or some of the more qualitative measures, general practice, I think, has been in the most parlous state in the now 40-year history of Medicare. And that is why, unapologetically, we have focused so squarely on getting general practice back on its feet. When a general practice is not working, you see that reverberate through hospital emergency departments. Which is why we've been so focused on our Urgent Care Clinic policy as well. Now, that doesn't mean there aren't other pressures right across the healthcare system. Some of them predated COVID. Some of them really emerged from COVID. Some of them are long standing, like dental. You know, let's be honest about the history of Medibank and Medicare, there was a policy decision not to include dental care in either of those two schemes of universal health insurance. When we were last in government, we made a contribution to addressing that for children of families on Family Tax Benefit that's had an important impact for those children and their oral health. But we know that oral health remains an issue of concern. There's an important Senate Committee Inquiry there. There's work that we're doing with health ministers. I don't pretend that that is going to be easy, or there's going to be a quick response to that. It's a long-standing structural issue in healthcare in Australia. But you know, I guess I can say we're unapologetic about our focus on general practice being the priority of our, of our efforts in primary care. But we know there are other pressures that we need to address over time as well.
JOURNALIST: You were saying before that when we get the new data explaining where the holes are in general practice and bulk billing, that people will be informed and call around and find their own way and make their own decisions. But for those who are in absolutely remote areas where you have one option if they're not going to bulk bill, and so these incentives aren't making them want to offer them, what's the alternative for them? Because for a lot of people, like you can't expect them to travel thousands of kilometres.
BUTLER: We're particularly cognisant of those issues outside, particularly, of our major cities. As I said, it's, it's harder to recruit doctors. Many of the doctors who've been a mainstay of those regional communities are either retiring now or indicating that they intend to retire over the coming five years. I mean, that's a real pressure across the system, but particularly in regional communities. It's part of the reason why the incentives to bulk bill are higher in regional communities than they are in the big cities. They're big in the big cities: that's about a 34% increase in income for a standard GP consult in Adelaide or Sydney or Melbourne. But it's a 50% increase in most regional towns. That's a big increase in income to towns that tend to be a little older, so probably have more pensioners and concession cardholders coming through their front doors. We also announced, only over the last couple of weeks, an increase in workforce incentives for GPs to work in regional communities with specific skills like emergency management, mental health, obstetrics and such like, there's quite a detailed program of workforce incentives to get people out into the regions: GPs, nurse practitioners and others. But we know there's long been a particular pressure on ensuring that equity that I've talked about that was the really the cornerstone of Medicare includes geographic equity, that's particularly the case for regional communities. But increasingly, we're seeing it in outer suburbs as well.
JOURNALIST: Minister, on mental health, I'm going to get the acronyms wrong but the psychologists association and the psychologists society, I believe, is still calling for you to redouble the 20 subsidised appointments under the Better Access, but they're also saying that the rebates are not adequate enough to actually meet the cost. People are spending 100 bucks more on psychologist appointment, is that something that you're looking at in the lead up to the Budget?
BUTLER: Can I say there are two issues there, Josh, let me address them both. The first is: Better Access has been around for around 20 years. The first scheme to give Medicare rebates for psychological therapy not delivered by a doctor but delivered by, usually, a clinical psychologist, but also social workers and OTs. And for those 20 years, with the exception of the COVID period, there was a maximum of 10 or 12 sessions. It was a scheme designed, really, for psychological therapy for people with mild to moderate disorders, usually the high prevalence ones like anxiety and depression. And over the course of its life, the average number of sessions that patients have needed and accessed have been four, five or six. Now as a time-limited measure, in response to COVID and particularly lockdowns, the former government doubled the number of sessions from 10 to 20. In their March 2022 Budget, which covered the financial year 2022-23, that measure was budgeted to come to an end on 31st of December 2022. Because it was essentially a COVID lockdown measure, and that was a decision taken by the former government. Now, I don't see Peter Dutton or Anne Ruston reflecting that. But it was a decision that they took. And the evaluation of Better Access, which happens every 10 years, the evaluation that happened to be received about the same time in December 2022, showed a couple of things.
Firstly, this scheme remains quite inequitable in terms of its accessibility in outer suburbs, certainly in regional communities and for people on lower incomes. But it also demonstrated quite clearly that that those additional sessions from 10 to 20 had actually had the effect of bottlenecking the supply for people to get into the scheme in the first place. So that tens of thousands fewer people were able to access any psychological therapy than it then had been the case before the additional 10. So those additional 10 came to an end in the end of calendar 2022. I'm pleased to say that last year, 45,000 more people got access to therapy than had the previous year, I think reflecting what a number of experts in the field had said: that if you remove that bottleneck that was created by the additional 10 sessions, more people will get access to some therapy. And I'm pleased to say that's the case. But there remain a number of other challenges in this scheme. Equity is really critical, in terms of the accessibility generally. And affordability is one as well. I've got a group from the mental health sector working with me closely we worked over the course of the second half of last year. We’re reconvening sometime in the next several weeks to start our work, again, to particularly address those findings of the evaluation of the Better Access scheme and see how we go forward.
JOURNALIST: On the rebate, so is that something that you are mindful of or concerned about: that people are having to pay $120 out of pocket to get one of these appointments that they are now able to get?
BUTLER: What the evaluation found about affordability, which was the gap fees were climbing quite sharply, is a finding of the evaluation that, as I've said, that group is working with us on. As to you know, the budget submissions that the groups that you talked about Josh have put in, they'll be considered in the usual way.
JOURNALIST: Labor's been sharpening its sales pitch to middle Australia last couple weeks. I guess looking to the Budget, you've talked a lot about last Budget and concessional patients and bulk billing. What are you looking at for non-concessional cardholders, what can middle Australia expect in the upcoming Budget towards lowering their GP fees.
BUTLER: I think I've addressed that, really. Last year, we delivered very substantial relief that was focused particularly on non-concession card patients around cheaper medicines. That delivered about $240 million in savings for medicines costs for general patients, so people who don't have that concession card. That gives them access to much cheaper medicines that are available to pensioners and concession card holders. As for what we considered in the Budget, you know that that's a matter that will be revealed in May. But as the Treasurer and the Prime Minister, the Finance Minister have said, as well, we're looking to a range of ways in which we can continue to help, particularly middle Australia, deal with the cost of living pressure that they're facing.
JOURNALIST: Minister, again, so you received that evaluation more than a year ago. Now, that evaluation also did recommend extra sessions be retained for people with complex mental illness. When will your government respond to that evaluation? And you acknowledge that that group of people with complex mental illnesses has been left in the lurch in the last 12 months, while that support was withdrawn?
BUTLER: No, I don't accept that. And the reason why I don't accept that is that the evaluation also found that the additional 10 sessions were not particularly going to people with more complex needs. Actually, the self-assessed mental health or mental illness of people going into the Better Access scheme was no different, according to whether or not they access the additional 10 sessions, or they didn't. So, I mean, what the evaluation found was that, yes, there was a challenge in providing adequate levels of support to people with more complex needs. But if you dig into that evaluation, there's nothing to indicate that the additional 10 sessions was particularly going to people with more complex needs. My concern about the Better Access scheme is that, essentially, it's not well designed to triage people with more complex and severe needs for additional sessions, for example, compared to those who would be quite adequately supported, as they traditionally have been, with four to six sessions of cognitive behavioural therapy, you know, under the existing arrangements for 10 sessions. So, you know, one of the really important elements that this group that I'm working with is working on, is how you can deliver better support for people with complex and severe needs, short of the very acute needs that are dealt with in the state acute system. But something beyond the traditional primary care scheme, whether that's headspace for young people or Better Access, often for older adults. The Head to Health centres that we're rolling out are one way in which we can do that. But we recognise that this is a particular challenge. I just don't accept that it's a challenge that that is able to be dealt with by simply adding additional sessions to Better Access, which is a demand-driven scheme, without a strong triage system.
JOURNALIST: And so, what’s the timeline for that reform?
BUTLER: This is complex work. And I think every member of the mental health sector who's joined with us in this discussion recognises that this, and some other issues like affordability and equity, they're not easy issues to address. But we're determined to do it. I don't have a particular date on which we'll be able to make an announcement about that. But I do say it's an important piece of work for me this year. This is a group I'm chairing. It's a series of sessions I'm involved in directly. And it's something we're determined to address. Thanks very much.

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