Albanese sold his big health promise to the people. The fight isn’t over yet

As Anthony Albanese basked in electoral glory last weekend, an American eye doctor gave a crowd of surgeons in Sydney a piece of advice that wouldn’t be lost on the prime minister.

“If you’re thinking about making a change to your healthcare system … ask yourself one question: Does America do that thing?” Dr Will Flanary, better known online as Dr Glaucomflecken, told the Royal Australian College of Surgeons’ annual scientific congress on Sunday.

“If America does that thing … let me just say, don’t do that.”

Australians have long treated the US health system as a cautionary tale, and since the return of Donald Trump, they have only grown more unimpressed with what they see happening across the Pacific.

Labor knew it. It went to the polls with a pitch to boost Medicare and make GP visits free again. It painted opposition leader Peter Dutton, who tried to introduce a $7 GP fee when he was health minister, as the man who might take it all away.

“If you ask people what they think works here much better than America, most Australians would put health at the top,” says Health Minister Mark Butler. “Dutton had a record of trying to introduce a user-pays system of healthcare for GP visits … and that was really a more American style of healthcare than what people identify as quintessentially Medicare, or quintessentially Australian.”

Albanese swept to re-election on a pledge to make nine in 10 GP visits free by the end of the decade. To deliver, he will need to defy gravity. Bulk-billing rates have been in freefall since he came to office in 2022, and while a $3.5 billion boost in 2023 left children and concession cardholders better off, millions of Australians still can’t remember the last time they visited a doctor without paying.

‘Not going to happen’

First, Albanese will need to sell his plan to hundreds of GPs yet to be convinced they would be better off abandoning gap fees and embracing bulk-billing for all patients.

“What the government needs to do is make the expectations clear,” says Australian Medical Association (AMA) president Dr Danielle McMullen. “They need to make sure patients don’t expect 100 per cent bulk-billing [when the scheme begins] on November 1 because that’s clearly not going to happen.”

The $8.5 billion scheme, which extends the incentive paid to GP practices that choose to bulk-bill all patients, did not go down with doctors as well as might have been expected from such a lucrative investment.

Throughout the government’s first term, doctors’ groups including the AMA and the Royal Australian College of General Practitioners (RACGP) told Albanese and Butler they wanted higher Medicare rebates without the obligation to bulk-bill. This was to make up for a six-year freeze (that ended in 2019), and save clinics from an avalanche of soaring rent, electricity, insurance and labour costs.

“They wanted the investment without strings attached,” says Butler. “You’re not going to get me to agree to that.”

But perhaps the government didn’t attach enough strings to its record funding, says Professor Henry Cutler, a health economist who advised the government on its latest review of primary care incentives.

“What Labor proposed, particularly with bulk-billing, was good politics, poor policy,” says Cutler, director of the Centre for the Health Economy at Macquarie University. “[Medicare] hasn’t changed in the last 40 years, and that is a problem because we have greater chronic disease, more need for multidisciplinary care and a fee-for-service model [that] really isn’t delivering the care that people need.”

He says several reviews in Labor’s first term recommended sweeping changes to the way primary care is funded, such as creating payments to fund multidisciplinary teams with GPs, nurses and allied health working together.

“The $8.5 billion that was pledged by government really doesn’t talk to that at all,” says Cutler. “It is a continuation of the status quo.”

In a recent poll of 283 doctors by the RACGP, two-thirds said they didn’t intend to increase bulk-billing in response to the proposal.

If a GP practice in metropolitan Sydney or Melbourne agreed to bulk-bill all patients, the Health Department calculates their rebate per standard appointment would rise from about $42 to just under $70.

McMullen says that might be enough to convince a GP who has only recently begun charging a fee under $30, but it is well short of the $40 gap fees that are now commonplace at major city clinics (the AMA fees guide estimates GPs should charge about $102 – including the Medicare rebate – for a standard consult to meet costs).

Butler says the scheme won’t suit everyone, but based on national billing data, the government estimates three-quarters of clinics would be better off. “That can get us to a 90 per cent bulk-billing rate across the country over time,” Butler says.

Another common argument from GP groups is that the flat-rate incentive encourages quick consults, and financially penalises doctors who spend longer with patients that may have more complex or chronic conditions.

“If you’re doing a lot of seven-minute appointments, this actually works very well,” says Dr Kean-Seng Lim, a GP in Mount Druitt in Sydney’s west. “If you have a practice where you are spending a lot more time with patients, then this actually doesn’t work very well.”

But Dr Edias Shumba, a GP in a Werribee clinic in Melbourne’s south-west, which bulk-bills about 90 per cent of its patients, says the length of appointments is determined by what a patient needs.

“If you have a patient that you always see for 20 minutes because they have a serious condition, but there’s a day when … they just need a medical certificate, why would you do a 30-minute consult just to prove that you care so much? You saw them two days ago,” Shumba says. “Most doctors, they want to do a good work. They want, they feel good when they know that they’ve diagnosed something that could have killed someone.

“I think the majority focus on that … and let the finances take care of itself.”

Werribee Medical Centre, where Shumba works, is owned by ForHealth, the country’s second-largest primary care provider. Chief executive Andrew Cohen, who has appeared alongside Butler and his assistant minister, Ged Kearney, at several media events spruiking the government’s health policies, says the new incentives will have an immediate effect on bulk-billing at about 100 GP clinics owned by the company nationally.

“On November 1, we will switch from one in 10 [clinics that bulk-bill], to six in 10,” Cohen says. “Suddenly, the bulk-billing model is sustainable from our perspective, it’s sustainable from an investment perspective, and most importantly, it’s sustainable from a doctor’s perspective.”

Cohen says the company is looking to build 50 additional clinics over the next two years, targeting “bulk-billing deserts” in regional and outer metropolitan communities where the incentives are more lucrative. Clinics that don’t change their practice may be left behind.

“It’s all well and good to say you won’t do it, but if next door opens up and they’re bulk-billing, that’s competition,” Cohen says.

Around the country, Labor enjoyed swings in seats where bulk-billing has declined rapidly in the past six years. In NSW, it picked up the electorate of Hughes, taking in Sutherland, where bulk-billing rates have dropped by 10.5 per cent since March 2019.

In Victoria, the ALP won Michael Sukkar’s seat of Deakin. The electorate takes in parts of Maroondah, Manningham and Whitehorse council areas, all of which have had a drop of least 5 per cent in bulk-billing over the same period.

Such communities could expect to benefit from the bulk-billing incentives – and give Albanese the sharpest blowback if they do not flow through to patients.

‘They’re using them because they’re free’

Butler says the popularity of the government’s bulk-billing promises can’t be separated from its pledges to invest in women’s health, make medicines cheaper and build dozens of new urgent care clinics.

The prime minister made a point of visiting an urgent care clinic in Dutton’s electorate of Dickson on the first day of the campaign, the first of many visits spruiking an initiative Butler admits was “pretty friendless” when he announced the first 87 clinics in 2022.

An interim review of the clinics, published on the eve of the election, estimated they had prevented 334,000 emergency department visits nationally.

Taxpayers covered about $246 a visit, more than the government pays for GP visits but less than the estimated $616 for equivalent non-urgent visits to emergency departments. There have been ongoing teething problems in recruiting GPs and getting access to medical imaging services out-of-hours.

Macquarie University’s Cutler said it was not yet known whether the clinics were taking pressure off emergency departments as intended, but they are at least giving Australians access to some form of free healthcare – something that feels increasingly unreachable for many.

“People are using them, and most likely they’re using them because they’re free compared to a general practitioner,” Cutler says. “So in that regard, urgent care clinics are delivering.”

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