By Theo Van Lieshout
Just over a week ago I admitted three children to hospital from a primary health care clinic. The first was a four-year-old boy with dehydration secondary to persistent diarrhoea and vomiting. Later in the same day, another young child with the same symptoms required admission. The next day, a third child with the same symptoms also required admission.
I was puzzled by this cluster of cases, but because each child had a different surname, I presumed them to be unrelated. I mentioned the names of the children to one of the health workers and found out that all three families were living under the same roof in a housing commission house. Seventeen people were living there: eight adults and nine children.
With the help of a public health registrar, a nurse and two health workers, we decided that all household contacts of the three children required a single dose of an antiprotozoal agent to nip this mini-epidemic in the bud.
I spoke to the chief pharmacist of the local public hospital where the children had been admitted and was told that 20 doses of the agent, tinidazole, at $2.46 each would cost about $50.00. I asked the pharmacist if we could have them for free, but at the hospital's expense.
All of the children were inpatients for about five days and at $500 a day for hospital treatment, the hospital had already spent $7500 on treating the outbreak. If the $50 outlay would be likely to prevent even one more admission, the hospital would be better off.
The pharmacist contacted the medical superintendent, who agreed to waive the cost.
After organising for all the occupants to be at the house at the same time, a small team from the clinic went out and treated most of the occupants and a few more later in the day. The exercise took a couple of hours.
Consider if these three families had all taken out private health insurance "to take the burden off the public system". Had the hospital been a for-profit private hospital, it would have been a financial boon to wait for increased cases and potentially treat all 20 patients, making $50,000, less costs.
Furthermore, if I were a shareholder in the hospital, I might make a tidy profit out of one small diarrhoeal epidemic in one house if a public health role was deliberately ignored.
This example illustrates the folly of the federal government putting across the notion that the private sector needs boosting in order to assist the public sector. There are three propositions which appear to underlie the government's thinking in this policy direction.
First, that Medicare is unsustainable without additional private finance. Second, that private health insurance provides an important source of funds which takes pressure off the public system. Third, that the goals of equity of access to health care should be delivered through private financing.
The government is offering tax incentives for people to take out (or at least not drop) private health insurance. These financial incentives are estimated to result in an increase in Commonwealth government outlays of $509.5 million in the 1997-98 financial year. It is well recognised that most of this money will be a bonus to existing fund members.
If the objective is to reduce the pressure on the public hospital system, then it will be a lot more effective to pay these funds directly to public hospitals. This would also be more equitable, in that all Australians would have access to public hospitals, not just the 30% with private insurance.
One can easily get bogged down in figures. However, as a doctor, I look at the human scenario above in the light of the three propositions underlying the federal government's thinking.
First, no private finance will help the 17 people in this household; they can just afford to exist in an overcrowded environment and could not even entertain the idea of taking out private health insurance.
Second, a private system solution of treating all the diseases, making a profit and having no public health philosophy in the understanding of disease pathology actually increases the cost of health care to the community.
Third, in relation to the equity of access being provided through the private sector argument, one can only say that if you believe that you help the poor by helping the rich, you will believe anything.
The rhetoric of the government which proceeds along the lines that higher income earners should not be "bludging" on the public system by not taking out private health insurance is insulting to higher income earners who choose to insure through Medicare alone.
The notion of "middle class welfare" assumes that the well-off should not make use of public hospitals. It assumes that my children must be sent to private schools. Does it allow me to use public transport, the public library, roads?
The principle of Medicare is that the wealthier pay more of their income so the needier in the community who get disproportionately more illnesses get the same high standard of health care.
The principle of the private hospital industry is fundamentally to make a profit like any other business.
Another policy move of the federal government is to split off Medibank Private from the Health Insurance Commission. Medibank Private currently insures about 25% of Australians who possess private health insurance. In the current climate of wholesale deregulation, one could envisage a time when this entity will be sold off to corporate interests.
For doctors, the risk is managed care, whereby medical decision making will be subsumed to board room financial imperatives.
For patients, the government's policy of providing financial incentives for the privately insured will necessarily be reflected in a decrease in public health expenditure. The future for Medicare is bleak despite promises made to the contrary.
Parasites have been around a long time. It is better to prevent them than treat epidemics when they arise. By analogy, we had in Australia a private system that until now behaved, to be charitable, symbiotically with the public system. The government is moving towards encouraging the private system to become a parasite.
[Abridged from New Doctor, journal of the Doctors Reform Society.]