Selling health and GPs to an electorate in the Trump era

20 minute read


As yet, neither party has staked the ground on healthcare and GPs in the manner they both need to if they are taking any notice of what just happened in the US.


The alarm bells ringing about the Coalition and healthcare policy should have peak organisations for GPs and other key healthcare sector advocates a lot more worried than they seem to be.

So far the Coalition thinks it’s fine to have no real policies (what they have so far is listed in our story in TMR’s sister publication, Health Services Daily here – it’s free to access) and rely on publishing negative platitudes and disinformation about bulk billing and the government’s track record.

A big worry here is that Labor won’t see the need for a “Bruce Highway” moment in its health electioneering.

On 6 January Prime Minister Anthony Albanese gazumped the Coalition badly by committing to an investment of $7 billion to upgrade the dilapidated major coastal highway in Queensland.

It was the first big campaigning coup of the election. The Coalition came out and matched the funding promise but the moment was gone. Labor had notched up a a big tick in minds of Queenslanders, a state it is going to need to do well in come the election, some time before 17 May.

The Coalition’s policies on health are scant and show a distinct lack of interest or understanding of how our health system has started a critical transition which everyone needs to be careful with. Such a nonchalant approach might tempt Labor to rely on its relatively sound track record of investment in new policy directions over the past few years.

There are clear problems with taking this approach though.

First, the Coalition is fine with running a serial disinformation campaign.

Just this week Senator Anne Ruston told Australian Doctor that “under every metric that you could measure health, the current government has got the worst record”.

“Whether that be an 11% drop in bulk-billing rates since they’ve been in government, or the fact that we have had the greatest or highest level of out-of-pocket costs that have ever been seen before.”

These statements are rubbish.

But who is checking? And, I guess, who cares?  It’s easy to say anything and blur what is actually going on in the current media cycle with an electorate blunted with so much misinformation and disinformation.

Last year Labor spent more on the health system than any other government in each of the 20 years prior, including a lot on GPs through the tripled bulk-billing incentive and raising the overall bulk-billing rate. The last Coalition government kept GP rebates frozen for every year of its 10-year term. It’s impossible to reconcile a statement saying that on “every metric” the government is “the worst on record”.

Senator Ruston’s 11% bulk-billing headliner is disinformation writ large.

Technically, the figure is correct, even perhaps a little understated. But Senator Ruston is comparing the bulk-billing rate during covid, when vaccines were rushed to the population and had to be bulk-billed en masse. Therefore the bulk-billing rate skyrocketed for a period to nearly 92%.

It’s not a meaningful comparison. It’s a political one. Something that sits neatly in the era of Trump.

Bulk billing has dropped under Labor by something like 7-8%, but the trigger for this decline was in large part 10 years of a rebate freeze creating a GP sector so financially traumatised that in September 2021, the then-RACGP president made a public call to all GPs to reduce bulk billing and start mixed billing.

A couple of weeks back Senator Ruston published a press release on bulk billing based on the results of a survey from a small for-profit privately run doctor directory company. This was more misinformation (based in ignorance rather than knowing) than disinformation, but the narrative of the flawed survey was too tempting for Senator Ruston.

The survey made bold statements about the number of GP practices called (6995 is the claim), but had no baseline data on how many GPs actually answered the calls, what questions they were asked, had no published methodology, and when pressed, the group admitted that of those practices they got through to (it can’t have been many) the questions were asked of the practice receptionist – an employee, not a doctor or owner, who isn’t qualified to answer questions on bulk billing rates and usually not authorised to answer such questions either.

The survey published bulk-billing rates which bear little relationship to actual Medicare data which is released in full for everyone to check properly, every month.

Senator Ruston didn’t care. She likely didn’t check. She quoted the survey as if it were a valued and respectable long-term reference source. It was a small private company content marketing PR stunt.

Does this necessarily mean the Coalition would be bad for healthcare and the GP sector?

It’s not a good start. But when you add historical decisions and positions on health policy from both Mr Dutton and Senator Ruston it does get quite a bit worse.

Both the Opposition Leader (who was once voted the worst Health Minister in 35 years by Australian Doctor readers – we didn’t exist back then to ask) and Senator Ruston have the worst of track records in understanding health and delivering good policy of just about any politicians still in parliament.

Last week Charles Maskell-Knight published a piece which elegantly laid out some of the history and the likely problem that such a history points to if the Coalition wins.

After promising “no cuts to health” during the 2013 election, the Coalition’s first budget cut healthcare spending by over $6 billion over four years. The cuts included abolishing the National Preventative Health Agency, Health Workforce Australia and GPET.

Mr Dutton and Senator Ruston’s individual positions on Medicare in 2014 have a real air of “tigers don’t change their stripes” about it.

In a 2014 speech Mr Dutton flagged an overhaul of Medicare and said Australians who could afford it should pay more for their healthcare. He said he wanted a frank, fearless and far-reaching conversation about the health system, saying that the current system was unsustainable and that he wanted to “modernise and strengthen” Medicare.

He then introduced the idea of co-payments and that we needed payment models where those that could afford to pay, contributed directly.

Although not perfect, that’s sort of what mixed billing is doing now, but in an emerging pattern of “wrecking” where you can, so far both Senator Ruston and Mr Dutton have run the line that Labor has created a cost-of-living crisis by allowing mixed billing to rise in the overall payments model.

Simple question: if Mr Dutton and Senator Ruston want patients to pay more for Medicare, as they’ve indicated in the past, isn’t that going to contribute to the cost of living of those patients?

What does Mr Dutton really believe now about health given how strongly he stood his ground in 2014 on these matters of policy and that neither he nor Senator Ruston have come out and been explicit about maintaining the current trajectory and commitment to public hospital funding (they cut this in 2014 too), Medicare bulk billing and the PBS?

Senator Ruston famously announced the following to the Senate in December 2014:

“Everybody would like to think that we could go on in life with universal healthcare, with universal education and with all these wonderful things that over the last 20 years Australians have come to accept as a given. Unfortunately, the credit card is maxed out.”

Fast forward to the above press release from Senator Ruston’s office which was replete with false figures and assumptions suggesting trends in bulk billing that don’t exist according to actual data available from Medicare.

Does this sound like someone with an actual dog in the fight of seriously improving our healthcare system for providers and patients?

The press release is lazy.

Quoting 11% bulk billing as a meaningful figure , under normal circumstances, would be considered stupid.

The thing is, lazy and stupid is politically on trend at the moment.

If Labor plans on resting on its track record of investment in Medicare, its investment outside Medicare in things like urgent care clinics and hospitals, in openly resisting private health insurance’s push to fund general practice for their members (which is against the law currently), and a comprehensive digital health agenda aimed at making the whole system far more efficient, it’s not planning well enough for this election.

The details aren’t important unfortunately in such a febrile electoral environment.

Lazy and stupid can win an electorate over with the right conditions of voter discontent and disinformation. You need to be bold, tactical and smart,much like Albo was with his Bruce highway announcement.

Lazy and stupid in the US just signed a presidential executive order that will exit the US from the World Health Organization. That single idiotic and self-serving decree has the potential to kill millions of people worldwide come the next pandemic.

A big problem facing peak health bodies and persons of influence in this election that doesn’t seem to have been thought through yet is that our healthcare system is fundamentally different to 2014 when both Senator Ruston and Mr Dutton were keen to redo Medicare and get patients to pay a lot more for their care.

It’s been changed substantively by covid, and the subsequent rise of telehealth which has underpinned the rapid growth of a non-Medicare privately funded health ecosystem, where most of the rules of Medicare don’t apply.

This fast growing market-based (nice term for profit-driven) healthcare provider economy has a lot of growing influence and power in the system. And it suits Mr Dutton’s historical narrative of reshaping Medicare to a tee.

Most of these groups – the big private health insurers, who are pushing hard into general practice and want the Health Insurance Act changed so they can fund their members to pay for gap fees; the big private telehealth platforms; the new vertically integrated monoliths such as Wesfarmers-backed Instant Scripts, the vertically integrated online cannabis providers, and so on – have business models which operate largely outside of Medicare and which naturally align to the core Coalition philosophy of delivering market driven efficiency.

Indeed, the narrative of many of the leaders of some of these groups – who often have no medical background and simplistically view health like finance, retail, travel and other digitally transformed markets – is that the whole system is broken and needs to be disrupted. The narrative is also of course that the disruption is patient centric. But it’s profit centric first, no matter what they say – if it isn’t they don’t survive.

The private health insurers are buying up general practice networks with a plan that is about leveraging their position in the system for more membership revenue. Yes, they say they want to deliver continuity of care, but who for? Not for everyone, which is what Medicare is trying to do.

The four big private health insurers answer to shareholders first and patients second unfortunately, as much as they will say their strategies are patient-centric. They are patient centric to the degree that they are member-centric and members equal revenue and profit. Unfortunately private health insurance does not represent all all patients. That’s what government and Medicare have to worry about. And it’s becoming a bigger and bigger worry.

Mr Dutton is particularly friendly to the private health insurance sector. If he doesn’t come out and explicitly say he’s not going to support private health insurers providing cover for members’ gap fees in general practice, everyone needs to worry.

There are of course reasonable arguments that private health insurance has an important place in our current funding paradigm, but if you cross the private health insurance GP funding Rubicon – it’s a natural decision for a Coalition government to make based on their pro market-leading philosophies – then we would be setting out on a path to a two-tiered healthcare system, just like the US.

Think this can’t happen?

In 2014 Mr Dutton as the federal health minister came out in support of one our big private health insurers conducting a pilot scheme in Queensland that was designed to guarantee members priority bulk-billed care.

The trial allowed members to have access to a GP within 24 hours for a standard daytime visit and for after-hours access.

At the time Mr Dutton told the ABC:

“I am interested to see the outcomes of the trial in Queensland and I’m open to involvement of insurers. They cover 11 million Australians, and if they can help keep those people healthy and getting more regular access to primary are that is good for the health system as a whole.”

BUPA is already offering members free GP consults. They are doing that via a telehealth service (called Blua) that is manned by doctors from Doctors on Demand, which is owned by one of our largest emerging cannibis prescribing platforms.

A big problem here for everyone is that the Coalition doesn’t have to defund Medicare, or even touch it, to denude it and perhaps eventually make it completely unstable.

All they have to do is lean into the rapid rise of the non-Medicare provider economy. And if they get really cocky if they win with a majority, they could change the law so the private health insurers can fund GP gaps for their members.

That’s all market-driven philosophy, and goes to the very public statements from both Mr Dutton and Senator Ruston that we need more “user pays” because the government simply can’t afford to fund Medicare the way it has been.

It’s not that the private system doesn’t belong in healthcare. The private sector is vital in lots of ways.  It’s where innovation mostly comes from and it’s used very efficiently to help implement complex government infrastructure programs.  

It’s just that health is a very different beast from other market sectors in terms of how private groups can contribute productively. Profit, health and patient well being are a very tricky mix to balance.

In the hands of people who don’t even understand where you get the real data for bulk billing, and who proselytise about efficiency, small government and the power of markets, while suggesting we spend hundreds of billions of dollars of taxpayers money on unproven nuclear technology which might blow up all the momentum we have built in an energy transition probably more critical to the country than the health transition, we could all have a very big problem here.

Just one change to the Health Insurance Act which is market friendly could put us on a firm path to the disastrous two-tiered system that exists in the US and has created a healthcare system that costs its people 17% of GDP (compared to our 9%) and is grossly inequitable.

Another key aspect of healthcare that is not going to be apparent to voting Joe and Betty Punter, or explainable in any way that will get votes, is the transition that the current government has backed in digital health.

Does anyone remember that the last Coalition government actually defunded the Australian Digital Health Agency?

In the last three years that group has done a significant amount on policy and in starting on the implementation of a pretty bold vision of transformation of the underlying infrastructure of system, with a view to making health data accessible at all points of the system and to patients in real time (the “sharing by default” protocol). It’s not cheap.

In New Zealand, a new conservative government scrapped its entire investment in healthcare interoperability because they didn’t understand what it was.

System transformation via healthcare interoperability has occurred in the US already with great effect. It has occurred despite a ruinous healthcare system created by hugely dysfunctional funding environment dominated by private health providers, who – you guessed it – fund general practice for their members in a vertically integrated private funding model.

This all happened in part because of all the things that the Republicans hate the Democrats for and vice versa, on the concept of healthcare system interoperability , the two parties have been violently bipartisan for more than two decades.

It doesn’t feel like the Coalition and Labor are violently bipartisan on healthcare interoperability, for the very simple reason that the Opposition doesn’t understand it.

Talking to persons who have discussed this aspect of the healthcare system with the people that matter in the Coalition, the view is that there is virtually no understanding at all of digital health and what it could do for the system. That might be why the Coalition defunded the ADHA in its last stint in power. They didn’t understand, so they decided to save the money, a bit like what happened in New Zealand recently.

To be clear, this is not an op-ed saying don’t vote for the Coalition.

That’s just not going to happen for a large proportion of long-term glued-on Coalition voters. And depending on how the whole “are you better off than you were three years ago” Coalition campaign (it worked for Trump) flys, many people who are involved in health and are worried by all this might still have personal and family cost of living priorities they think trump (pun intended entirely) thinking of the possible implications for our health system.

No, this is more an op-ed saying, hey, the Coalition do not have the first clue about health so everyone needs to be careful.

Their track record and philosophy look like they align dangerously with the rise of a non Medicare provider economy and without them understanding what is going on a lot better they could easily and unwittingly set us on a path to a US-style system and the actual end of Medicare. Which might mean that Mediscare is in many respects in play.

What could everyone do (Coalition and Labor voters alike)?

Two suggested things here, one of which Senator Ruston and Mr Dutton could do if someone sends them this op-ed, but if they did, great, for reasons which will become obvious.

This week the RACGP decided to up the ante on its call for improving the funding of GPs by asking not for 20% but now a 40% increase to the C and D rebate for bulk billing. Our story on that is here.

The college has asked for the 20% increase in past elections and been duly ignored by both parties because it’s a lot to ask for in one chunk. So both parties might just ignore the college ask as an even bigger ambit claim than the past when both parties ignored them, and move on.

But both parties might want to stop this time and think a bit more about the opportunity in what the college is pitching.

Talking toThe Medical Republic this week, RACGP president Dr Michael Wright explained that the college had worked with a major consultant to cost the 40% increase, including some estimate of system savings as well. The cost year on year that would be something like $700 million to $1 billion (so let’s say $4 billion in a budget cycle). The identifiable savings to the system through things like reduced hospital admissions would be about $300 million. You could pitch that at only $400 million per year, except no one counts or believes the savings to the system side.

Dr Wright then explained a few things that both parties would do well to think carefully about. Yes, it’s a lot of new budget commitment – especially for Labor which has already committed a lot of new money in existing policy – but as far as cost of living, access to a GP a defining commitment to strengthening Medicare goes (remember Mediscare, Peter), it would almost certainly be a home run electoral healthcare pitch.

It’s expensive, but whoever goes first with this expensive but defining policy, would nail healthcare as far as most of the electorate would be concerned. No need for messy detailed explanations of past investments, positions or new plans. Pitch this and nothing else would likely matter.

It’s a policy that does what policies need to do in this era of Trumpian politics:

  • It’s simple and definitive messaging that deals with cost of living, access to GPs and securing Medicare.
  • It has lots of upstream nuance if it does grab the electorate from which whatever party pitches it can expand on, like they really know what they’re doing.
  • It immediately positions who ever does it first as the leader in one of the most most important election battle grounds – health.

Oh, there’s also a lot of other good arguments for doing it, which probably wouldn’t even try to go to with the electorate (don’t want to complicate things these days) – like, funding long consults like this nip a lot of complex chronic care patient problems in the bud early and prevent a lot more long-term cost to the system if these patients end up in hospitals.

And that female GPs tend to dominate long-term consults, and given they are rebated so low at the moment, such a move would significantly improve the income profile and morale of our female GP workforce.

Trump wouldn’t like that last point of course. Obviously woke.

The thing is, health is a big potential election winning lever for either party, if one or the other wants to take the plunge and go for their “Bruce highway” moment.

Both parties quickly committed $7 billion to upgrading the Bruce highway with a view to winning in Queensland. The first one that came out with it is the party that voters associate with such a big cut-through policy.

We’re only talking a $3 to $4 billion policy commitment tops to lock up the cost of living, access to GPs and secure Medicare arguments in health.

If you asked Labor it might rightly think that it’s spent more than any government in two decades on health last year so Treasury would go nuts.

But we aren’t talking about balancing a budget here. We’re talking tactics to win an election in the era of Trump.

The first party to do it will likely get that Bruce Highway effect.

It’s surprising to me that neither has jumped on it yet.

Which brings me to the final point of this op-ed: the Coalition could easily win and it doesn’t feel like any of the major peak provider bodies or key government department heads have had a really good sit down with Mr Dutton or Senator Ruston and explained what is really going on, and what they should understand intimately before letting loose on a system that is clearly in a lot of transition.

It’s going to be way too late to do this after the election. The Coalition will be giddy with success if they win with a clear majority, and we know from last week in the US what the extreme of that can look like.

It’s not entirely the fault of Mr Dutton and Senator Ruston that they have no policies and that those they have are mostly weak and disjointed.

It’s at least partly the fault of everyone who is immersed now in building out a better system that an opposition party is going into an election on health with so little understanding of what could go wrong if they tried changing things without a little more core knowledge and understanding of the nuances first.

Someone could even have a go at convincing the Coalition that leaning too far into the rapidly emerging non-Medicare provider economy could easily trip the system to a trajectory that would take us the way of the US.

I’m not sure you’d get very far, but it’s a debate that should at least be had with Mr Dutton and Senator Ruston.

And now.

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