***Check against delivery***
On this day, 18 months ago, Australians went to the polls and cast their vote, a vote that would end the Morrison Government and nine years of cuts and calculated neglect to Medicare.
Today, as we look ahead to the 40th anniversary of Medicare in February, I want to provide an update on the Albanese Government’s efforts to strengthen Medicare and provide some reflections on the road ahead.
It’s no secret that when we came to Government, general practice was at its most parlous condition in the 40-year history of our system.
It had never been harder and never more expensive to see a doctor, and bulk billing was in sharp decline.
Pensioners, concession cardholders, families with young kids, all were being told that at the front desks of general practices everywhere their visit was no longer bulk billed.
“Put the Medicare card away, and pull out your credit card instead.”
The former government had been telling us that everything was rosy, that bulk billing was at an all-time high – a rate of nearly 90% they said.
But in this, the Morrison government was characteristically loose with the truth.
It concealed the true extent of the decline in bulk billing behind a smokescreen of temporary COVID measures.
Millions upon millions of bulk billed COVID tests and vaccinations – all of which had to be bulk billed – were artificially inflating the numbers.
It was only once we were elected, and I directed my department to report the statistics more transparently and more regularly, that Australians began to see the true state of bulk billing.
Once all those temporary COVID measures were set aside, it was clear that bulk billing had been in real trouble for quite a while.
In the year to June 2020, the first year pre-pandemic, just over 67% of patients – 2 in 3 - had every GP visit bulk billed.
By the 2022 election, that had fallen to little more than 64%.
For adult concession card holders, pensioners and other concession card holders, the fall was even more significant.
The bulk billing rate had dropped by fully five percentage points from 2018 until the 2022 election.
The true bulk billing rate – the one that actually told us whether Australians were paying gap fees when visiting the GP – wasn’t 90% at all, it was more like 64%.
A six-year freeze to Medicare rebates that started under Peter Dutton was really starting to bite, and particularly starting to bite because of global inflation shock swept through the Australian economy, and the impacts are still being felt today, with the bulk billing rate for the most common GP consultations continuing to decline as data we published early last week shows.
But bulk billing wasn’t the only area where cracks were showing.
The signs of a system under strain were everywhere.
As you all know, Medicare is facing a range of demographic headwinds.
The population is ageing, and chronic conditions are increasingly common.
And as the College of GP’s Health of the Nation Report showed last week, more and more Australians are presenting to GPs with mental health concerns or seeking diagnoses for developmental disorders.
Patients have increasingly complex needs that require the care of a team of health professionals, rather than a single GP, who might be working alone.
None of these headwinds are new.
And a number of people in this room, indeed, have been sounding the alarm on some of these trends for many years.
50 years ago, one quarter of the population had a chronic condition – only 1 in 4.
But 15 years ago, that figure had climbed to around 40%.
And 10 years ago, when Peter Dutton was sworn in as Health Minister, the ranks of Australians with a chronic condition had swelled to about half.
And Australia was getting older, too.
The proportion of Australians, as you all know, aged over 65 years of age has grown over recent decades.
From 1 in 12 when Doug Everingham was Health Minister under Gough 50 years ago.
To just 1 in 7 when Peter Dutton was Health Minister.
The demographic headwinds were reaching gale force, and the warning signs of a system under pressure were everywhere.
Coalition scuttles the ship
But instead of taking evasive action to right the ship, Peter Dutton started to scuttle it, throwing the oars overboard, and burning the life rafts.
Because just as it is in Labor's DNA to strengthen Medicare, it is in the Coalition's to weaken and to undermine it.
The Liberal Party has always had a deep ideological antipathy to Medicare, ever since Malcolm Fraser abolished its predecessor, Medibank.
The father of the modern Liberal Party, John Howard, called bulk billing an “absolute rort” and threatened to “pull Medicare right apart”.
When he was the Health Minister, Peter Dutton famously lamented that there were, in his words, “too many free Medicare services” and began a program of cuts and neglect to deal with that.
He tried to do away with bulk billing altogether, by introducing a tax on every visit of every person to a GP.
And when Labor and the Parliament blocked that, Peter Dutton and the Coalition froze the Medicare rebate for six long years, ripping literally billions out of our primary care system.
And even though a record number of Australians were needing regular medication for their chronic conditions, he also tried to jack up the price of medicines, by up to $5 a script.
Is it any wonder, really, that Australia’s doctors voted Peter Dutton the worst Health Minister in the Medicare era?
What followed was a program of calculated neglect.
Pilots were launched, only to be mothballed by the next Liberal Health Minister – something the Grattan Institute has described as “more pilots than Qantas.”
Recommendations from medicines experts were ignored.
Strategies were announced with no funding to deliver them.
And My Health Record stagnated, bungled and full of bugs – really old technology.
And in the rare occasion that a Liberal Health Minister was prepared to deviate from neglect they were usually blocked by their party room.
Like when my predecessor Greg Hunt, to his eternal credit, introduced regulations to ban the import of vapes and e-cigarettes just as that market was beginning.
He was rolled by his own party room in a matter of days and his import ban had to be junked, and we’ve seen what has happened since.
Another reform not implemented. More calculated neglect.
Because here’s the thing that we all understand in health: reform is challenging and without political will, it’s frankly impossible.
So, by 2022, as Australians went to the polls 18 months ago, Medicare was really taking on water and urgent action was needed.
Strengthening Medicare and its beating heart
That’s why my immediate priority was to chair the Strengthening Medicare Taskforce and bring together representatives from across the health sector to agree on the road to reform.
And in the May Budget, we began to walk that road, delivering an historic 6.1 billion dollar package to strengthen Medicare, including the largest ever investment in bulk billing that took effect only three weeks ago.
This was a much-needed injection of funds, delivered alongside more foundational reforms to enable the kind of multidisciplinary team-based care that Australians today need.
The tripling of the bulk billing incentive for more than 11 million Australians took effect on the first of this month.
Because for Labor, bulk billing is the beating heart of Medicare.
5 million families with kids under 16 and 7 million adult pensioners and concession cardholders will now find it easier to see a bulk billing doctor.
These patients account for around 3 out of 5 visits to the GP, and in some communities much more than that, meaning a very significant increase to general practice income.
For a doctor in a major city the Medicare payments they now get to bulk bill these patients for a standard consult have increased this month by 34%.
For a doctor in regional and rural Australia, Medicare payments for that sort of consult have increased by around 50%.
In the Hunter, Doctor Yasas Samarasinghe said it is a “lifeline”.
And in the Northern Rivers of New South Wales, Doctor Ken Stockley told us: “it is going to encourage those that have recently changed to private billing to go back to bulk billing.”
And even in these early days, only three weeks into the new incentives, that is exactly what we are seeing across the country, clinics everywhere making that shift.
General practices that were charging gap fees before the tripling of the incentive and have now shifted to bulk billing again, for every child under 16, every pensioner, every Australian with a concession card that comes through their doors.
Rural and regional Australia will benefit the most, since the incentives are considerably higher as towns get further and further away from the state’s GPO. And as well, practices there often serve a patient cohort that is older and more likely to hold a concession card.
More team-based care
The Albanese Government’s reforms to strengthen Medicare are changing the game across a whole range of areas for practices and patients alike.
A new Medicare rebate for GP consultations longer than 60 minutes became available for the first time on 1 November, to give GPs the time they need to provide better care for patients with really complex needs.
In just the first 18 days, there have been several thousand of these Level E consults already delivered under Medicare.
We’ve also given GPs the support they need to grow their nursing and allied health workforce teams, by increasing the workforce incentive payment by up to 30% and for the first time, indexing it every single year.
Since 1 July, this has provided a much needed boost to the nearly six thousand practices that receive the incentive, helping them support more than 21 thousand health practitioners, including 16 thousand nurses.
Smaller practices that simply don’t have the means or market to bring on permanent staff will soon be able to call on the services of nurses and allied health practitioners, through a 77 million dollar program of PHN commissioning and practice support.
I really want to see this program delivered by our Primary Health Networks to innovate – to explore opportunities for them to try new things like social prescribing through social workers and the like.
Cheaper medicines helping hip pocket and health
Then there are our cheaper medicines reforms.
Delivering the largest cut to the maximum co-payment in the 75 year history of the PBS saving Australians more than 200 million dollars in just 10 months. And that 20 million dollars in savings per month will continue into the future.
We reduced the PBS Safety Net Threshold last year, so more pensioners and concession cardholders get free medicines, sooner, reducing the yearly medicine costs for those 2 million Australians by as much as 25% this year.
And of course - a little controversially – delivering 60-day prescriptions for six million Australians with a chronic condition, with 600 thousand 60-day scripts already issued in the first two months.
These important cost of living measures in the area of medicines are not just good for the hip pocket, they are also good health policy.
We simply can’t strengthen Medicare for the 21st century without also strengthening the PBS.
A 30-day script made a lot of sense when chronic conditions were rare and patients would usually attend their pharmacy with a short illness seeking a one-off course of medicine.
A 30-day script makes less sense today, when half the patients have a chronic condition, and many of them are on the same medicine, not just for years, but often for decades at the same dose, or even for the remainder of their life.
Cheaper medicines benefit patients with both their hip pocket and we know it improves medication compliance, so it improves their health as well.
Upgrading My Health Record
Patient benefit is what is driving Labor, in all of these things.
Take, for example, the upgrades to My Health Record.
Only 1 in 10 specialists use My Health Record.
Just 1 in 5 diagnostic reports in radiology are uploaded.
The other four just disappear into the digital ether.
Patients find this so frustrating, as I know, do GPs, because every lost test result means another day off work, another waiting room, another procedure and perhaps another gap fee.
What a complete waste of time and money and poor productivity. For patients and for the health system.
If a patient gets a diagnostic scan or pathology test, particularly when it’s reimbursed by Medicare, then those results should be uploaded.
At the moment, this happens by exception. Because it is not the rule.
I intend to make it the rule because, frankly, patients expect it to be the rule.
Against that clear and compelling patient benefit, arguments that change is too hard or too expensive are just not good enough anymore.
MyMedicare as the foundation of a stronger Medicare
Because building a stronger Medicare will mean change.
Changes like the introduction of MyMedicare.
MyMedicare is the foundation upon which a stronger, more personalised Medicare is going to be built.
Patients will get more tailored quality care from their regular practice, their regular GP and health team.
Practices will get better information about their registered patients.
MyMedicare will help Medicare go beyond the limitations of fee-for-service, with a range of blended funding packages to help practices tailor care to patients from priority groups.
It’s still early days since registration opened on 1 October, but already nearly 370 thousand patients have registered, along with more than 5,000 general practices.
And the benefits of this system-wide reform will grow over time, as more patients and more providers join.
The first two blended funding packages will become available in the middle of next year.
One will be targeted at the more than 13 thousand patients that present to hospital 10 or more times in a given year.
And the other at the nearly 200 thousand Australians in residential aged care.
Practices registered for MyMedicare will be paid incentives to provide their registered patients in aged care with regular visits and care planning.
The development of the funding package for that group has been worked through with stakeholders and can now be announced.
The incentives include, $300 per patient, per year to be paid quarterly to the GP him or herself, and $130 per patient, per year to be paid quarterly to the practice.
Rural loadings will apply, with payments increasing in line with the remoteness of the community.
Importantly, these funding packages sit on top of the existing fee-for-service, they don’t replace it – all existing Medicare rebates will continue to be paid as well.
Responding to the global health workforce crunch
As well as strengthening the funding structures that enable health teams to do their important work we also need to support more health workers in those teams to actually do that important work.
Professor Mark Cormack’s “Unleashing the Potential of our Health Workforce Review” will find the opportunities for everyone in our highly educated health workforce to provide single every ounce of care that they can.
Because that will also free up our doctors to focus more on the complex conditions that only they can treat.
The first batch of consultation took input from across the health sector, with more consultation opportunities next year before the final report is delivered next October.
I’d like to see every health professional work to the top of their skills, training and experience, but we particularly need to break the glass ceiling that has held back our highly educated nurses and nurse practitioners.
When I was last in the health portfolio under Julia Gillard, there were around 2,000 nurse practitioners in Australia.
Ten years on, and there are still around 2,000 nurse practitioners in Australia, and maybe five or six hundred of them aren’t able to get jobs as nurse practitioners.
In the Budget, we committed to raise the Medicare rebates for nurse practitioners by 30%, remove the legislated collaborative arrangements that continue to restrict their autonomy, and build that workforce with a large scholarship program.
Reviewing the workforce levers
But we can’t kid ourselves: the global health workforce crunch is not going to be solved overnight.
While part of the solution will be in changing who Medicare supports to deliver care, the other part will be in changing how and where Medicare supports them to deliver that care itself.
Importantly, the Monash Modified Model, the system of District of Workforce Shortage, and Distribution Priority Areas.
These levers we currently have to spread doctors and health workers around the country are from a very different time, before the COVID pandemic and before the global health workforce crunch.
Which is why we are going to undertake a wide-ranging review to urgently investigate how to more equitably distribute doctors and other health workers across the country.
The “Working Better for Medicare Review” will look at how current policies and programs can be strengthened to make it easier to see a doctor, a nurse or other health worker in the outer suburbs of our major cities, as well as obviously in regional, rural and remote Australia.
The Review will be led by nurse, advocate and remote health expert Professor Sabina Knight, as well as former senior health bureaucrat and academic Mick Reid.
It will be underpinned, again, by extensive stakeholder engagement, with findings expected to be provided to government in the middle of next year.
The road ahead: following the north star of patient benefit
Remaking Medicare for the 21st century will take persistent evolution, not overnight revolution.
It took nine years of cuts and neglect to bring Medicare to the weakened state that we inherited.
It will take time again to strengthen it.
When I stood before the National Press Club on the eve of the May Budget, I made a promise.
I said “with every gradual, foundational change that we make, we will put the needs of patients first.”
And in our first 18 months we have done exactly that.
As we continue to take the hard choices, I fully expect that some will oppose them, just like the Liberal Party opposed:
- Chifley’s PBS in the 40s.
- Whitlam’s Medibank in the 70s.
- Hawke’s Medicare in the 80s.
- or our 60-day prescriptions in 2023.
Change can be scary, because with change comes risk.
But the risk of not changing our current system is far greater.
We can’t keep trying to treat 21st century Australia with 1980s Medicare.
So we will listen to all good arguments and evidence about the way forward, but our north star is – and will always be – patient benefit.
And that means actually listening to patients.
Which is why we have invested $20 million to support patient voices, including:
- a new body in health for Culturally and Linguistically Diverse Australians
- expanded the capacity of the Consumers Health Forum to play their important role
- and finally, establishing two new mental health peak bodies – one for consumers and one for carers.
Because in a sector, as you all know, full of stakeholders with loud voices and sharp elbows the patient voice has too often been the quietest in these debates.
That needs to change.
Conclusion: Medicare at 40
On the first of February next year, Medicare turns 40.
Just as I am doing today, in years to come, I’m sure that another Health Minister will one day stand before CEDA and chart the reforms of our Government.
I know that when they do that, the 2022 election and the years that followed will be seen as an inflection point coming to the end of the COVID pandemic in the history of Medicare.
A time when Government and the sector worked together to right the ship and navigate through choppy waters and strong headwinds that we face.
Five years from now, I hope that Medicare will be:
- better connected, and;
- digitally enabled;
- will be delivered by health teams, and;
- underpinned by blended funding models;
- with a strong beating heart of bulk billing;
- with more workers delivering care;
- in more parts of the country.
In short, I hope that five years from now, Medicare will be stronger.
Because that is exactly what the people of Australia elected our government to do.