Health is defence – Universal care vs ‘user pays’

Guest post

Gold Coast GP Dr Andrew Rees submitted this thought-provoking guest post about universal health care vs a ‘user pays’ system.

For some decades now, we Australians have been living in a country where basic health services have been provided with heavy government subsidies or in many cases have been provided at no direct cost to patients.

Now the Australian Liberal government wants to change the system so that it is more predominantly ‘user pays’. Despite ample evidence that such a system is more expensive and inefficient than our present approach, and that the care delivered is no better, there is a desire to adopt what has been demonstrated to work poorly elsewhere in the vain hope that it will work well here.

I understand that there are those who believe that universal health care or anything approximating it is a ‘Socialist’ idea. Preventing disease and treating the sick and injured might, however, be regarded as a way of protecting the community from harm. Indeed, we have other institutions established by the government to protect our community. The civil authorities include the fire, ambulance and police services. The Army, Navy and Air Force provide military defence. Customs and Border Protection also play a role.

So, some might say, “Why do I have to pay for the Air Force? If I had a constitutional right to bear arms (we don’t), then I could just buy my own jet fighter and go and shoot up any bad guys. Socialists have forced this on us, surely. Bunch of Commies making us pay for armed forces. Police, too. Nobody ever broke into my house. Why should I have to pay taxes so the police can investigate your burglary? You got burgled – you pay for it!”

The reason that we, as a society, tend not to think this way (although I am sure that there are some who do) is that there is recognition that some services are best provided on a universally available and publicly funded basis.

In fact, Section 51 of the Australian Constitution provides Federal Parliament certain powers including ‘to make laws for the peace, order, and good government of the Commonwealth with respect to (for example) “… the naval and military defence of the Commonwealth …” and a little later on “… pharmaceutical, sickness and hospital benefits, medical and dental services” …’

It seems to me, therefore, that those who framed the Australian Constitution recognised that providing ready access to health services was a way of protecting the nation as a whole. Sick people are less productive than the well. Infectious diseases spread easily without treatment and where appropriate, vaccines and quarantine. That individuals owe a debt of care to other members of a society is not a new thought:

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee. (John Donne)

The Australian Government has a Constitutional obligation to protect the Commonwealth. Attacking and weakening the health system whether delivered in the doctor’s office or in a State run (ultimately Federally funded) hospital suggests a lack of resolve on the part of Government to discharge this duty. A person who mounted such a spirited attack against his or her own defence force in a time of war would probably be regarded to have committed treason.

However, because the enemies those health professionals protect the community from are more insidious – such as smoking, heart disease, cancer, and infectious diseases – there is a perception that this kind of attack on the health system and its practitioners is somehow acceptable.

If we accept that in ill-health we share a common foe, then as Thomas Hobbes’ states:

“Whatsoever therefore is consequent to a time of war, where every man is enemy to every man, the same consequent to the time wherein men live without other security than what their own strength and their own invention shall furnish them withal. In such condition there is no place for industry, because the fruit thereof is uncertain: and consequently no culture of the earth; no navigation, nor use of the commodities that may be imported by sea; no commodious building; no instruments of moving and removing such things as require much force; no knowledge of the face of the earth; no account of time; no arts; no letters; no society; and which is worst of all, continual fear, and danger of violent death; and the life of man, solitary, poor, nasty, brutish, and short. (Hobbes, Leviathan)

No doubt, the Liberal Government would reason that they are not attacking or endangering the system, but rather they are going to make it better. However, they have no evidence that their approach is likely to have any success. Rather, evidence from the US is that using a ‘user pays,’ predominantly commercial health fund system leads to burgeoning expenses and substantially decreased access for the majority of the community.

Under the US health system, Health Management Organisations (HMOs) may perversely interfere with the ability of appropriately trained physicians and surgeons to provide the most appropriate care because of a commercial requirement to maximise financial returns for the HMO.

Bacterium or bullet, cancer or cannon shell, tuberculosis or terror attack – the community is still worse off because of the suffering of the individual. Whether one dies from influenza or an improvised explosive device, one is still dead. Leaving citizens to fend for themselves and fund their own care will certainly reduce the number of attendances in the short term.

However, the real cost of a change to a predominantly ‘user pays’ system will be far greater. What kind of life is it that we seek for the members of our community? Neighbourly, prosperous, pleasant, lovely and long: or solitary, poor, nasty, brutish, and short?

Dr Andrew Rees

Disclaimer and disclosure notice.

10 thoughts on “Health is defence – Universal care vs ‘user pays’

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  3. Andrew I have read the Constitution. It does go on further to say it expressly the Government’s prime responsibility is to finance/pay for healthcare.

    In mid 2000, High Court Judge Justice Gibbs has expressly stated that the Government has no Constitutional right to interfere in the doctor patient relationship.

    Financing healthcare is also making sure the Commonwealth (the people) are getting value for money. The Government must start with by giving back, openness, transparency and accountability at every level right back to the patient. Health is more than just a virtuous ideology, there is a pragmatic side that needs to be argued without people shutting the doors on a healthy public debate. Every body has a good argument why health dollars should be spent on their pet project.

    My money is on, spend more money on healthcare prevention. Get providers and patients on side by starting off with better health literacy and engagement programs. There will be plenty of money left even for the armed forces. Preventable diseases can save over $2bn p.a. The annual health bill is $160 bn. Personally I would rather see this money in more local netball courts and football grounds.

    Prevention is always better than the cure. This is where a GP’s (incredible influence) little difference can make a mega impact e.g. let us talk about obesity in the consulting room without the fear of offending.

    Having said that, a doctor has a legal duty of care of a doctor to put their patient first and many good doctors do. There are more simple opportunities than problems in healthcare. Patients will thank and trust their GP more by being candid when others are to afraid to be.

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  4. Nice article. From a health workforce perspective, we already see the influence of large scale corporatisation of healthcare as smaller GP practices and regional hospitals struggle against the corporate leviathans when they are recruiting. A user-pays system can only make the medical workforce situation worse.

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    • Shaun I disagree, pay $5 and a maximum of $60 p.a. makes patients and providers more accountable to each other. Sometimes things for free leads to misuse and wastage no matter how noble the cause. It is about allocating resources to those in need. If people spend $$ on smokes and alcohol surely they can afford $5 to see you? We do not give these people free food and they are not all going hungry. It is hard to argue absolutes for every person. It is about allocative efficiency of the health dollar. Surely preventable diseases should be subject to some way of rationing . I would rather make this same money for free cancer treatments for kids. This is a much fairer system and will have a bigger impact over a person’s lifetime.

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      • David, my point wasn’t so much about the allocation of the health dollar (I am a recruiter, not an economist), but rather on the effect that HMO style organisations would have on the medical workforce in Australia. As I am sure you know, small practices struggle to compete with corporates who offer huge sign-ons, and seemingly endless loopholes to provider number policies. I think the end result of HMOs would be less doctors for regional and remote areas, GP practices closing their doors, and a questionable level of healthcare.

        That said, I don’t think you’re talking about HMOs- rather something a bit left of that on the continuum (‘user pays’ is a big umbrella term) – and I agree with you on that point. Plus, it’s a great incentives for GPs to stay in their own practices.

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      • I think they should implement the system similar to how the pharmaceutical prescription copayments started about 25 years ago (as mentioned in an Auspharm comment):

        Introduce the co-payment BUT do a few things along with it:

        1 – Cap the amount that each person pays throughout the year. E.g 52 co-payments after which the co-payment for that individual gets scrapped
        2 – Increase the fortnightly allowance they get from the government by the co-payment amount. Meaning that nobody is out of pocket but those who see medicos less than once a week actually benefit.

        And the co-payment itself should see the completely trivial times that a doc visit is not necessary, go down, more than making up the money spent for all those that fall under scenario 2 above.

        Liked by 1 person

  5. Your article is very one sided. You fail to recognize the value of collaboration. Are the tax payers worthy of the best possible care and deserving of accessibility. Physicians and Pharmacists can work together to improve patient care outcomes. Articles and opinions like yours fail to promote this important trend. Pharmacists are not amateurs, on the contrary we save you the physician from numerous errors you make. Gives credit where it’s due and appreciate Pharmacy and it’s important role in the provision of efficient, effective and timely patient care. Patients and local tax paying citizens will be the judge.

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    • I guess patronising any person or profession never helps progress a constructive debate. To the contrary ego and ignorance is a lazy way to squash what is in the patients best interest which is in everyone’s interest. Nobody has a monopoly on knowledge or morality. I agree collaboration across all sectors is key.

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