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

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