Making Medicare: the Politics of Universal Health Care in Australia

Abstract

MAKING MEDICARE: THE POLITICS OF UNIVERSAL HEALTH CARE IN AUSTRALIA Anne-marie Boxall and James A. Gillespie New South Publishing, 2013. ISBN: 9781742233437, 223 pages.This is an excellent book. It should be required reading for anyone involved in health and health financing policy, most particularly Commonwealth public servants advising the new Abbott Government.The book is a fair and balanced account of the long history of development and consolidation of Australia's universal health insurance system. It includes careful analysis of both the policy issues involved and the practical considerations of conflicting interests, implementation challenges, political factors and broader contextual environments. Although there may well be a broad consensus now about the basic framework for Medicare, much of this book's analysis is as pertinent today as it was in the 1950s, 1960s, 1970s, 1980s or 1990s when that framework was being debated so heatedly. There are many issues yet to be resolved and new challenges to be faced that require both expert policy analysis and pragmatic understanding of politics and administration.The book's carefully researched history is presented so as to test several theories of political discourse when it comes to health and health financing. The main one, highlighted in the book's substantial introduction, is the balance between the roles of ideas, interests and institutions. Correctly, in my view, but disappointingly, the authors conclude that although all three matter, interests and institutions have dominated the Australian debates. In the last chapter they state that the highly politicised context in which Medicare became a fixture in Australian life was more marked than in any comparable country, and that the structural problems that have emerged have not benefited from rational debate.The book includes chapters on each stage of Medicare's history, beginning with a summary of developments before the 1950sthat led to the Menzies-Pagescheme, followedby chapters on the background to Whitlam's Medibank proposals (1960-74), making Medibank a reality (1974-75), the Fraser health system reform (1976-81), the introduction of Medicare by Hawke, the politics of Medicare (1984-96) and the Howard years. These chapters are more than descriptions of events, although the descriptions are detailed and well researched: they include considerable analysis of the various factors at work during each period. This analysis is supplemented by several chapters focusing on some key debates: 'Organised medicine versus Medibank', 'Medibank weighed in the balance' and 'Why Fraser abolished Medibank'.Afinal chapter discusses current issues and future challenges.There are many fascinating aspects of the history. Despite the partisan nature of the heated debates at each stage of health reform, any ongoing philosophical divide between the major parties is overshadowed by the debates within each party that continued over decades. Menzies resigned in 1939 when his proposed national contributory scheme, which would have provided universal cover, was shelved. His later support for a voluntary private health insurance system was for him a second- bestapproach. KeyLabourPartyfigureswerestillfirmlyopposed to Medibank and its fee-for-service approach, even after the dismissal of the Whitlam Government in 1975, whereas key Coalition ministers, including even Fraser, genuinely intended to maintain Medibank even if they were never passionate supporters.More important than the 'ideas' were the interests and institutions. The medical profession won the battle in the 1940s for fee-for-service against not only the advocates of a salaried national health system along the lines of the British National Health Service, but also against advocates of private approaches, who saw advantage in the friendly societies' use of 'lodge payments', which were like capitation grants. The subsequent challenge, debated for decades (and still relevant today), was to find an affordable and equitable system consistent with fee-for-service. …